Healthcare Provider Details

I. General information

NPI: 1457386963
Provider Name (Legal Business Name): PRISCILLA ROTH-WALL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 N BUTLER AVE STE 115
FARMINGTON NM
87401-6425
US

IV. Provider business mailing address

3751 N BUTLER AVE STE 115
FARMINGTON NM
87401-6425
US

V. Phone/Fax

Practice location:
  • Phone: 505-787-2640
  • Fax: 505-787-2789
Mailing address:
  • Phone: 505-787-2640
  • Fax: 505-787-2789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY1470
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPSY1470
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1470
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: