Healthcare Provider Details

I. General information

NPI: 1114214558
Provider Name (Legal Business Name): ROSELI CAVALCANTE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 GARVER LN
LOS ALAMOS NM
87544-3571
US

IV. Provider business mailing address

382 GARVER LN
LOS ALAMOS NM
87544-3571
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-5955
  • Fax:
Mailing address:
  • Phone: 505-629-5955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number330768
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: