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General NPI Number Information
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NPI Number | 1538425541
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Entity Type | Organization
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Legal Business Name | PEDIATRIC BEHAVIORAL MEDICINE, INC
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Dates
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Enumeration Date | 04/03/2012
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Last Update Date | 02/26/2013
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Provider Practice Location Address
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Address Line | 2407 W PICACHO AVE A104
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City | LAS CRUCES
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State | NM
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Zip | 88007-4124
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Country | US
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Telephone | 575-805-0849
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Fax | 575-541-3617
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Provider Business Mailing Address
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Address Line | 2407 W PICACHO AVE A104
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City | LAS CRUCES
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State | NM
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Zip | 88007-4124
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Country | US
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Telephone | 575-805-0849
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Fax | 575-541-3617
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAMES W MARTIN
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Credential | MD
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Telephone | 575-805-0849
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | MD2008-0370
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD2008-0370
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | MD2008-0370
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License Number State | NM
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