Healthcare Provider Details

I. General information

NPI: 1902009665
Provider Name (Legal Business Name): PAMELA D. TENNANT HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 COPPER AVE NE
ALBUQUERQUE NM
87108-1473
US

IV. Provider business mailing address

5200 COPPER AVE NE
ALBUQUERQUE NM
87108-1473
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5099
  • Fax: 505-255-4206
Mailing address:
  • Phone: 505-255-5099
  • Fax: 505-255-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number317273
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: