=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912275124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR OSVELIA G DEEDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2011
-----------------------------------------------------
Last Update Date | 12/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5203 JUAN TABO BLVD NE STE 2B
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-2691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-850-5314
-----------------------------------------------------
Fax | 505-221-5710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1542 ROSALBA ST NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-6552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-850-5314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | DAWN HALFACRE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-352-5269
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1095
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------