Healthcare Provider Details

I. General information

NPI: 1902914831
Provider Name (Legal Business Name): ELLIOT J RAPOPORT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 JOHNSON STREET
SANTA FE NM
87501-1828
US

IV. Provider business mailing address

301 JOHNSON STREET
SANTA FE NM
87501-1828
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-3757
  • Fax: 505-982-3300
Mailing address:
  • Phone: 505-983-3757
  • Fax: 505-982-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberNMBPE 225
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: