Healthcare Provider Details

I. General information

NPI: 1528603743
Provider Name (Legal Business Name): CHILD PSYCHOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 11/12/2019
Certification Date:
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: 662-603-1035
  • Fax:
Mailing address:
  • Phone: 662-603-1035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. PRISCILLA ROTH-WALL
Title or Position: PSYCHOLOGIST/OWNER
Credential: PH.D.
Phone: 662-603-1035