Healthcare Provider Details

I. General information

NPI: 1962810150
Provider Name (Legal Business Name): SANTA FE PSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 BROTHERS RD SUITE B
SANTA FE NM
87505-6975
US

IV. Provider business mailing address

2204 BROTHERS RD SUITE B
SANTA FE NM
87505-6975
US

V. Phone/Fax

Practice location:
  • Phone: 505-795-5566
  • Fax: 505-998-1362
Mailing address:
  • Phone: 505-795-5566
  • Fax: 505-998-1362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: BROOKE ROBERTS
Title or Position: OWNER
Credential: PSYD
Phone: 505-795-5566