Healthcare Provider Details

I. General information

NPI: 1447562145
Provider Name (Legal Business Name): MICHAEL MAULDIN, PH.D., L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 ANYA RD
CORRALES NM
87048
US

IV. Provider business mailing address

154 ANYA RD
CORRALES NM
87048-8581
US

V. Phone/Fax

Practice location:
  • Phone: 575-937-6458
  • Fax:
Mailing address:
  • Phone: 575-937-6458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1072
License Number StateNM

VIII. Authorized Official

Name: DR. MICHAEL A MAULDIN
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 575-937-6458