Healthcare Provider Details

I. General information

NPI: 1124001904
Provider Name (Legal Business Name): ROGER THOMAS PRAY PH.D., ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 PROPPS ST NE
ALBUQUERQUE NM
87112-1554
US

IV. Provider business mailing address

10200 PROPPS ST NE
ALBUQUERQUE NM
87112-1554
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-1778
  • Fax:
Mailing address:
  • Phone: 505-379-1778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1102
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: