=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003587684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY HYZY AMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2021
-----------------------------------------------------
Last Update Date | 04/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 CANDELARIA RD NE STE B
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-1965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-273-6300
-----------------------------------------------------
Fax | 505-265-7860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3301 CANDELARIA RD NE STE B
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-1965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-273-6300
-----------------------------------------------------
Fax | 505-265-7860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | CTB-2022-0103
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------