Healthcare Provider Details

I. General information

NPI: 1285563718
Provider Name (Legal Business Name): CODY JACKSON CROLLETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10899 MONTGOMERY BLVD NE STE B
ALBUQUERQUE NM
87111-3935
US

IV. Provider business mailing address

10899 MONTGOMERY BLVD NE STE B
ALBUQUERQUE NM
87111-3935
US

V. Phone/Fax

Practice location:
  • Phone: 505-460-7103
  • Fax: 505-709-1354
Mailing address:
  • Phone: 505-460-7103
  • Fax: 505-709-1354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: