Healthcare Provider Details

I. General information

NPI: 1538425541
Provider Name (Legal Business Name): PEDIATRIC BEHAVIORAL MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2407 W PICACHO AVE A104
LAS CRUCES NM
88007-4124
US

IV. Provider business mailing address

2407 W PICACHO AVE A104
LAS CRUCES NM
88007-4124
US

V. Phone/Fax

Practice location:
  • Phone: 575-805-0849
  • Fax: 575-541-3617
Mailing address:
  • Phone: 575-805-0849
  • Fax: 575-541-3617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2008-0370
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2008-0370
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD2008-0370
License Number StateNM

VIII. Authorized Official

Name: JAMES W MARTIN
Title or Position: PRESIDENT
Credential: MD
Phone: 575-805-0849