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General NPI Number Information
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NPI Number | 1104578319
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Entity Type | Organization
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Legal Business Name | MIMBRES PSYCHOLOGICAL SERVICES
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Dates
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Enumeration Date | 01/19/2022
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Last Update Date | 01/19/2022
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Provider Practice Location Address
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Address Line | 2811 INDIAN SCHOOL RD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87106-1825
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Country | US
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Telephone | 505-358-0087
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Fax |
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Provider Business Mailing Address
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Address Line | 2811 INDIAN SCHOOL RD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87106-1825
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Country | US
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Telephone | 505-358-0087
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MIRIAM WHITTAM
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Credential |
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Telephone | 505-358-0087
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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