Healthcare Provider Details

I. General information

NPI: 1134278179
Provider Name (Legal Business Name): MAX MASTELLONE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N CAMPO ST
LAS CRUCES NM
88001-3433
US

IV. Provider business mailing address

2615 CASHMERE CT
LAS CRUCES NM
88011-0800
US

V. Phone/Fax

Practice location:
  • Phone: 609-706-5931
  • Fax: 505-521-6259
Mailing address:
  • Phone: 609-706-5931
  • Fax: 505-521-6259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0953
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number0953
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: