MEDICARE: DR. ROBERT S. CHANG PH.D., A.B.M.P.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1248	NM
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist	1248	NM
3	103TA0700X	Adult Development & Aging Psychologist	1248	NM
4	103TB0200X	Cognitive & Behavioral Psychologist	1248	NM
5	103TC0700X	Clinical Psychologist	1248	NM
6	103TC1900X	Counseling Psychologist	1248	NM
7	103TE1100X	Exercise & Sports Psychologist	1248	NM
8	103TF0000X	Family Psychologist	1248	NM
9	103TF0200X	Forensic Psychologist	1248	NM
10	103TH0004X	Health Psychologist	1248	NM
11	103TH0100X	Health Service Psychologist	1248	NM
12	103TM1800X	Intellectual & Developmental Disabilities Psychologist	1248	NM
13	103TP2701X	Group Psychotherapy Psychologist	1248	NM
14	103TP0016X	Prescribing (Medical) Psychologist	0037	NM

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1248	OTHER	NM	NEW MEXICO STATE BOARD OF PSYCHOLOGIST EXAMINER
2	0037	OTHER	NM	PRESCRIBING PSYCHOLOGIST

NPI Number	:	1144351586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT S. CHANG PH.D., A.B.M.P.

Provider Business Mailing Address
First Line	:	801 VASSAR DR NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-2725
Country	:	US
Telephone Number	:	505-248-4046
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 VASSAR DR NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-2725
Country	:	US
Telephone Number	:	505-248-4046
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	04/02/2018

4588 PARADISE BLVD NW , MEDICARE ADVANTAGE CLINIC
ALBUQUERQUE, NM
87114-4105

Practice Phone: 505-998-1840
Practice Fax: 505-998-1841