Healthcare Provider Details

I. General information

NPI: 1144177965
Provider Name (Legal Business Name): SKYLAR WILLIAMS GRANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE STE R
ALBUQUERQUE NM
87110-7825
US

IV. Provider business mailing address

1209 MOUNTAIN ROAD PL NE STE R
ALBUQUERQUE NM
87110-7825
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-8938
  • Fax: 505-445-4968
Mailing address:
  • Phone: 505-433-8938
  • Fax: 505-445-4968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: