Healthcare Provider Details

I. General information

NPI: 1083730980
Provider Name (Legal Business Name): ELENA BETTOLIVAUGHAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING BLVD NE PMG KASEMAN BEHAVIORAL MEDICINE
ALBUQUERQUE NM
87112-5046
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2536
  • Fax: 505-291-5327
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number644
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: