Healthcare Provider Details

I. General information

NPI: 1194017558
Provider Name (Legal Business Name): RIO GRANDE PSYCHOLOGICAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 LEBANON ARC
LAS CRUCES NM
88005-3749
US

IV. Provider business mailing address

11 LEBANON ARC
LAS CRUCES NM
88005-3749
US

V. Phone/Fax

Practice location:
  • Phone: 575-526-1036
  • Fax: 575-524-1317
Mailing address:
  • Phone: 575-526-1036
  • Fax: 575-524-1317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number542
License Number StateNM

VIII. Authorized Official

Name: DR. ROD MERTA
Title or Position: PRESIDENT
Credential:
Phone: 575-526-1036