Healthcare Provider Details

I. General information

NPI: 1023731825
Provider Name (Legal Business Name): BRAIN & BODY REHABILITATION PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CARLISLE BLVD NE STE 224
ALBUQUERQUE NM
87110-1664
US

IV. Provider business mailing address

3029 DELANO PL NE
ALBUQUERQUE NM
87106-2034
US

V. Phone/Fax

Practice location:
  • Phone: 505-688-0601
  • Fax:
Mailing address:
  • Phone: 505-688-0601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MARK PEDROTTY
Title or Position: PRESIDENT
Credential: PHD
Phone: 505-688-0601