Healthcare Provider Details

I. General information

NPI: 1033546486
Provider Name (Legal Business Name): NEW MEXICO STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF STEWART STREET AND SWEET AVENUE NEW MEXICO STATE UNIVERSITY O'DONNELL HALL #047
LAS CRUCES NM
88003-0005
US

IV. Provider business mailing address

PO BOX 30001 O'DONNELL HALL, ROOM 047
LAS CRUCES NM
88003-8001
US

V. Phone/Fax

Practice location:
  • Phone: 575-646-2065
  • Fax:
Mailing address:
  • Phone: 575-646-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN SCHWARTZ
Title or Position: ASSOCIATE DEAN
Credential: PH.D.
Phone: 575-646-4098