Healthcare Provider Details

I. General information

NPI: 1629558838
Provider Name (Legal Business Name): OCOTILLO PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MISSOURI AVE STE 36
LAS CRUCES NM
88011-9151
US

IV. Provider business mailing address

1830 MYRTLE AVE
LAS CRUCES NM
88001-5245
US

V. Phone/Fax

Practice location:
  • Phone: 575-635-2002
  • Fax:
Mailing address:
  • Phone: 575-635-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY1460
License Number StateNM

VIII. Authorized Official

Name: DR. TRACIE HITTER
Title or Position: ORGANIZER
Credential: PH.D.
Phone: 575-635-2002