Healthcare Provider Details

I. General information

NPI: 1134427545
Provider Name (Legal Business Name): BLUEBONNET CHILD & ADOLESCENT PSYCHIATRY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 N MESA ST SUITE 1
EL PASO TX
79912-5422
US

IV. Provider business mailing address

5505 N MESA ST SUITE 1
EL PASO TX
79912-5422
US

V. Phone/Fax

Practice location:
  • Phone: 915-532-9200
  • Fax:
Mailing address:
  • Phone: 915-532-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NOAMI M DIAZ
Title or Position: PRESIDENT
Credential: MD
Phone: 915-532-9200