Healthcare Provider Details

I. General information

NPI: 1376197392
Provider Name (Legal Business Name): THOMAS STEWART
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LASER RD NE
RIO RANCHO NM
87124-4517
US

IV. Provider business mailing address

500 LASER RD NE
RIO RANCHO NM
87124-4517
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0667
  • Fax:
Mailing address:
  • Phone: 505-896-0667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number227649
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: