Healthcare Provider Details

I. General information

NPI: 1841365699
Provider Name (Legal Business Name): ESPANOLA PUBLIC SCHOOLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 CALLE DON DIEGO
ESPANOLA NM
87532-3414
US

IV. Provider business mailing address

714 CALLE DON DIEGO
ESPANOLA NM
87532-3414
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-3342
  • Fax:
Mailing address:
  • Phone: 505-367-3342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number34659714
License Number StateNM

VIII. Authorized Official

Name: DR. DAVID COCKERHAM
Title or Position: SUPERINTENDENT
Credential:
Phone: 505-753-2254