Healthcare Provider Details

I. General information

NPI: 1750451746
Provider Name (Legal Business Name): BEHAVIORAL MEDICINE ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

601 W 2ND ST. STE 10
ROSWELL NM
88201
US

V. Phone/Fax

Practice location:
  • Phone: 505-623-9322
  • Fax: 505-627-6339
Mailing address:
  • Phone: 505-623-9322
  • Fax: 505-627-6339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number0966
License Number StateNM

VIII. Authorized Official

Name: DR. BRIAN KEITH WHITLOCK
Title or Position: CHIEF PSYCHOLOGIST
Credential: PH.D.
Phone: 505-623-9322