Healthcare Provider Details

I. General information

NPI: 1609301142
Provider Name (Legal Business Name): PAUL PELOQUIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 SAN PEDRO DR NE SUIITE J
ALBUQUERQUE NM
87110-4077
US

IV. Provider business mailing address

PO BOX 37068
ALBUQUERQUE NM
87176-7068
US

V. Phone/Fax

Practice location:
  • Phone: 505-850-6072
  • Fax: 505-256-3600
Mailing address:
  • Phone: 505-850-6072
  • Fax: 505-256-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1181
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: