Healthcare Provider Details

I. General information

NPI: 1689852709
Provider Name (Legal Business Name): BRIAN KEITH WHITLOCK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 2ND ST SUITE 10
ROSWELL NM
88201-4670
US

IV. Provider business mailing address

601 W 2ND ST SUITE 10
ROSWELL NM
88201-4670
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-9322
  • Fax: 575-627-6339
Mailing address:
  • Phone: 575-623-9322
  • Fax: 575-627-6339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number0966
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0966
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: