Healthcare Provider Details

I. General information

NPI: 1356604854
Provider Name (Legal Business Name): MARITA DELANEY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 E AZTEC AVE
GALLUP NM
87301-4803
US

IV. Provider business mailing address

P.O. BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-3828
  • Fax:
Mailing address:
  • Phone: 505-552-5300
  • Fax: 505-552-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number752
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: