Healthcare Provider Details

I. General information

NPI: 1275689515
Provider Name (Legal Business Name): PEGGY A KEILMAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4216 BALLOON PARK RD NE
ALBUQUERQUE NM
87109-5801
US

IV. Provider business mailing address

393 WALDEN RD
CORRALES NM
87048-8379
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-5470
  • Fax:
Mailing address:
  • Phone: 505-890-4239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number300
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: