Healthcare Provider Details

I. General information

NPI: 1558436964
Provider Name (Legal Business Name): ELIZABETH ANN PENLAND PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 HIGH RESORT BLVD SE PMG RIO RANCHO HIGH RESORT 4005
RIO RANCHO NM
87124-5906
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2402
  • Fax: 505-291-2490
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0797
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: