Healthcare Provider Details

I. General information

NPI: 1023334083
Provider Name (Legal Business Name): GRANO DE ORO FAMILY MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 7TH ST
LAS VEGAS NM
87701-4956
US

IV. Provider business mailing address

PO BOX 1856
LAS VEGAS NM
87701-1856
US

V. Phone/Fax

Practice location:
  • Phone: 505-617-6313
  • Fax:
Mailing address:
  • Phone: 505-617-6313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0811
License Number StateNM

VIII. Authorized Official

Name: DR. RODOLFO FIDENCIO GRANO
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 505-617-6313