Healthcare Provider Details

I. General information

NPI: 1235364969
Provider Name (Legal Business Name): INSIDE-OUT PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 GEORGIA ST NE STE B2
ALBUQUERQUE NM
87110-1390
US

IV. Provider business mailing address

3901 GEORGIA ST NE STE B2
ALBUQUERQUE NM
87110-1390
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-0225
  • Fax: 505-872-8045
Mailing address:
  • Phone: 505-385-0225
  • Fax: 505-872-8045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number812
License Number StateNM

VIII. Authorized Official

Name: DR. NANCY AEREN GRAU
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 505-385-0225