Healthcare Provider Details

I. General information

NPI: 1801169255
Provider Name (Legal Business Name): ERICA LANE CASTLEBERRY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HERMOSA DR NE
ALBUQUERQUE NM
87108-1023
US

IV. Provider business mailing address

31 CASA HERMOSA DR NE
ALBUQUERQUE NM
87112-7000
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-7946
  • Fax:
Mailing address:
  • Phone: 713-818-6978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1202
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: