Healthcare Provider Details

I. General information

NPI: 1104744655
Provider Name (Legal Business Name): UPSTREAM NEUROPSYCHOLOGY & THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N COURT AVE
FARMINGTON NM
87401-6941
US

IV. Provider business mailing address

210 N COURT AVE
FARMINGTON NM
87401-6941
US

V. Phone/Fax

Practice location:
  • Phone: 505-407-5852
  • Fax:
Mailing address:
  • Phone: 505-407-5852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES DANIEL MARQUEZ
Title or Position: OWNER/NEUROPSYCHOLOGIST
Credential: PSY.D.
Phone: 505-407-5852