Healthcare Provider Details

I. General information

NPI: 1407915416
Provider Name (Legal Business Name): SCC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10704 PASEO DEL NORTE NE
ALBUQUERQUE NM
87122-3112
US

IV. Provider business mailing address

10704 PASEO DEL NORTE NE
ALBUQUERQUE NM
87122-3112
US

V. Phone/Fax

Practice location:
  • Phone: 505-822-8223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number700031
License Number StateNM

VIII. Authorized Official

Name: DR. JAMES LOGAN
Title or Position: DIRECTOR
Credential:
Phone: 505-822-8223