Healthcare Provider Details

I. General information

NPI: 1790783868
Provider Name (Legal Business Name): DAVID CARTER HOLCOMB PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W HADLEY AVE
LAS CRUCES NM
88005-1806
US

IV. Provider business mailing address

PO BOX 245
SAN MIGUEL NM
88058-0245
US

V. Phone/Fax

Practice location:
  • Phone: 575-268-2634
  • Fax: 866-611-2571
Mailing address:
  • Phone: 575-522-5466
  • Fax: 575-521-8611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1056
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0765
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: