Healthcare Provider Details

I. General information

NPI: 1619213055
Provider Name (Legal Business Name): CHILDRENS PSYCHIATRIC CENTER OUTPATIENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE BLDG 2
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

2600 MARBLE AVE NE BLDG 2
ALBUQUERQUE NM
87106-2058
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2190
  • Fax: 505-272-3466
Mailing address:
  • Phone: 505-272-2190
  • Fax: 505-272-3466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DWIGHT RANDOLPH COLEMAN JR.
Title or Position: MENTAL HEALTH ASSOCIATE
Credential:
Phone: 505-710-1826