Healthcare Provider Details

I. General information

NPI: 1336312412
Provider Name (Legal Business Name): DR. PAUL A. MOSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 N PIEDRAS ST
EL PASO TX
79930-4210
US

IV. Provider business mailing address

5001 N PIEDRAS
EL PASO TX
79930-6400
US

V. Phone/Fax

Practice location:
  • Phone: 915-564-6100
  • Fax:
Mailing address:
  • Phone: 915-564-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number011404
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number011404
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number011404
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number011404
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number011404
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: