Healthcare Provider Details

I. General information

NPI: 1518600048
Provider Name (Legal Business Name): THE CENTER FOR DYNAMIC PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S SAINT FRANCIS DR STE B
SANTA FE NM
87505-4036
US

IV. Provider business mailing address

1221 S SAINT FRANCIS DR STE B
SANTA FE NM
87505-4036
US

V. Phone/Fax

Practice location:
  • Phone: 505-636-6550
  • Fax: 505-372-6979
Mailing address:
  • Phone: 505-636-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. BENJAMIN GREENBERG
Title or Position: DIRECTOR
Credential: PSYD
Phone: 505-636-6550