Healthcare Provider Details

I. General information

NPI: 1487910402
Provider Name (Legal Business Name): NORTHERN NEW MEXICO NEUROPSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 5TH ST STE 211
SANTA FE NM
87505-5403
US

IV. Provider business mailing address

1911 5TH ST STE 211
SANTA FE NM
87505-5403
US

V. Phone/Fax

Practice location:
  • Phone: 505-490-9049
  • Fax:
Mailing address:
  • Phone: 505-490-9049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1183
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1183
License Number StateNM

VIII. Authorized Official

Name: LAUREN PARKS
Title or Position: DIRECTOR
Credential: PHD
Phone: 505-490-9049