Healthcare Provider Details

I. General information

NPI: 1710053293
Provider Name (Legal Business Name): CYFD-STATE OF NEW MEXICO-TCM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 EDITH BLVD NE
ALBUQUERQUE NM
87107-2222
US

IV. Provider business mailing address

4000 EDITH BLVD NE
ALBUQUERQUE NM
87107-2222
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-2400
  • Fax:
Mailing address:
  • Phone: 505-331-8562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GREG NELSON
Title or Position: BUREAU CHIEF, CYFDJJS
Credential:
Phone: 505-331-8562