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General NPI Number Information
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NPI Number | 1750451746
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Entity Type | Organization
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Legal Business Name | BEHAVIORAL MEDICINE ASSOCIATES, INC.
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 601 W 2ND ST STE 10
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City | ROSWELL
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State | NM
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Zip | 88201-4670
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Country | US
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Telephone | 505-623-9322
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Fax | 505-627-6339
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Provider Business Mailing Address
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Address Line | 601 W 2ND ST. STE 10
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City | ROSWELL
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State | NM
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Zip | 88201
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Country | US
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Telephone | 505-623-9322
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Fax | 505-627-6339
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Authorized Official
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Title or Position | CHIEF PSYCHOLOGIST
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Name | DR. BRIAN KEITH WHITLOCK
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Credential | PH.D.
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Telephone | 505-623-9322
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number | 0966
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License Number State | NM
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