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General NPI Number Information
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NPI Number | 1275447062
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Entity Type | Organization
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Legal Business Name | NEW MEXICO NEURODIVERSITY CENTER
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Dates
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Enumeration Date | 09/30/2026
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Last Update Date | 09/30/2026
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Provider Practice Location Address
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Address Line | 3600 CERRILLOS RD STE 724D
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City | SANTA FE
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State | NM
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Zip | 87507-2690
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Country | US
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Telephone | 575-342-9178
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Fax | 575-252-4994
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Provider Business Mailing Address
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Address Line | 3600 CERRILLOS RD STE 724D
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City | SANTA FE
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State | NM
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Zip | 87507-2690
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Country | US
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Telephone | 575-342-9178
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Fax | 575-252-4994
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. JEDEDIAH WALLS
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Credential | LPCC-S, ATR-P
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Telephone | 575-342-9178
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | NULL
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