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General NPI Number Information
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NPI Number | 1124211404
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Entity Type | Organization
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Legal Business Name | STATE OF NEW MEXICO
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Dates
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Enumeration Date | 08/21/2007
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Last Update Date | 08/21/2007
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Provider Practice Location Address
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Address Line | 3695 HOT SPRINGS BLVD
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City | LAS VEGAS
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State | NM
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Zip | 87701-9549
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Country | US
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Telephone | 505-454-2100
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Fax |
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Provider Business Mailing Address
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Address Line | 3695 HOT SPRINGS BLVD
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City | LAS VEGAS
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State | NM
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Zip | 87701-9549
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Country | US
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Telephone | 505-454-2100
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Fax |
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Authorized Official
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Title or Position | INTERIM ADMINISTRATOR
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Name | STEVE MARTINEZ
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Credential |
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Telephone | 505-454-2203
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TP0814X
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Taxonomy Name | Psychoanalysis Psychologist
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License Number |
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License Number State |
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