Healthcare Provider Details

I. General information

NPI: 1154877371
Provider Name (Legal Business Name): J. MICHAEL MASH PRESCRIBING PSYCHOLOGIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 STATE ROAD 68 UNIT 6
RANCHO DE TAOS NM
87557
US

IV. Provider business mailing address

PO BOX 94508
ALBUQUERQUE NM
87199-4508
US

V. Phone/Fax

Practice location:
  • Phone: 575-776-7432
  • Fax:
Mailing address:
  • Phone: 505-384-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number609
License Number StateNM

VIII. Authorized Official

Name: JAMES MASH
Title or Position: OWNER/PH.D.
Credential:
Phone: 575-776-7432