Healthcare Provider Details

I. General information

NPI: 1841804473
Provider Name (Legal Business Name): MARY J SMITH SCHOOL PSYCHOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MICHIGAN ST. SOCORRO HIGH SCHOOL
SOCORRO NM
87801
US

IV. Provider business mailing address

1200 MICHIGAN ST. SOCORRO HIGH SCHOOL
SOCORRO NM
87801
US

V. Phone/Fax

Practice location:
  • Phone: 575-838-3112
  • Fax:
Mailing address:
  • Phone: 575-838-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number400521
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: