Healthcare Provider Details

I. General information

NPI: 1235435181
Provider Name (Legal Business Name): MICHELLE ULIBARRI PSY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 BRIDGE ST
LAS VEGAS NM
87701-3495
US

IV. Provider business mailing address

179 BRIDGE ST
LAS VEGAS NM
87701-3495
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-2554
  • Fax:
Mailing address:
  • Phone: 505-426-2554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number271289
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: