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General NPI Number Information
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NPI Number | 1457386963
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Entity Type | Individual
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Provider Name | PRISCILLA ROTH-WALL PH.D.
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Gender | Female
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 04/30/2020
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Provider Practice Location Address
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Address Line | 3751 N BUTLER AVE STE 115
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City | FARMINGTON
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State | NM
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Zip | 87401-6425
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Country | US
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Telephone | 505-787-2640
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Fax | 505-787-2789
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Provider Business Mailing Address
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Address Line | 3751 N BUTLER AVE STE 115
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City | FARMINGTON
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State | NM
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Zip | 87401-6425
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Country | US
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Telephone | 505-787-2640
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Fax | 505-787-2789
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | PSY1470
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 103TM1800X
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Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
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License Number | PSY1470
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY1470
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License Number State | NM
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