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General NPI Number Information
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NPI Number | 1598142762
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Entity Type | Organization
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Legal Business Name | RIO GRANDE NEUROSCIENCE LLC
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Dates
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Enumeration Date | 04/27/2015
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Last Update Date | 05/22/2015
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Provider Practice Location Address
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Address Line | 600 CENTRAL AVE SE SUITE 221
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-3656
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Country | US
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Telephone | 505-345-9288
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Fax | 505-212-0359
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Provider Business Mailing Address
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Address Line | 600 CENTRAL AVE SE SUITE 221
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-3656
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Country | US
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Telephone | 505-345-9288
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Fax | 505-212-0359
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Authorized Official
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Title or Position | OWNER
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Name | DR. JILL RYAN
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Credential | PH.D.
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Telephone | 505-412-0545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1147
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License Number State | NM
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