Healthcare Provider Details

I. General information

NPI: 1578771549
Provider Name (Legal Business Name): MONICA SMART ED.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 2ND ST
RATON NM
87740
US

IV. Provider business mailing address

PO BOX 947
EL PRADO NM
87529
US

V. Phone/Fax

Practice location:
  • Phone: 505-445-7090
  • Fax:
Mailing address:
  • Phone: 505-770-9136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number247907
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: