Healthcare Provider Details

I. General information

NPI: 1275447062
Provider Name (Legal Business Name): NEW MEXICO NEURODIVERSITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CERRILLOS RD STE 724D
SANTA FE NM
87507-2690
US

IV. Provider business mailing address

3600 CERRILLOS RD STE 724D
SANTA FE NM
87507-2690
US

V. Phone/Fax

Practice location:
  • Phone: 575-342-9178
  • Fax: 575-252-4994
Mailing address:
  • Phone: 575-342-9178
  • Fax: 575-252-4994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JEDEDIAH WALLS
Title or Position: DIRECTOR
Credential: LPCC-S, ATR-P
Phone: 575-342-9178