Healthcare Provider Details

I. General information

NPI: 1417174848
Provider Name (Legal Business Name): MS. PHYLLIS PINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E AZTEC AVE
GALLUP NM
87301-5509
US

IV. Provider business mailing address

222 NIZHONI BLVD APT E4
GALLUP NM
87301-5764
US

V. Phone/Fax

Practice location:
  • Phone: 505-721-1800
  • Fax:
Mailing address:
  • Phone: 505-793-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number257139
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: