Healthcare Provider Details

I. General information

NPI: 1245815158
Provider Name (Legal Business Name): JUDITH BIESEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 YALE BLVD SE
ALBUQUERQUE NM
87106-4383
US

IV. Provider business mailing address

933 BRADBURY DR. SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-7999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1622
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: