MEDICARE: AMANECER PSYCHOLOGICAL SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	40581	TX

General Provider Information

NPI Number	:	1639373566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMANECER PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	8 WILLIAMSBURG DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-4147
Country	:	US
Telephone Number	:	915-779-5600
Fax Number	:	915-779-5605

Provider Business Practice Location Address
First Line	:	6044 GATEWAY BLVD E STE 405
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79905-2037
Country	:	US
Telephone Number	:	915-779-5600
Fax Number	:	915-779-5605

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RODOLFO BASURTO JR.
Credential	:	PH.D
Telephone Number	:	915-779-5600

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	08/22/2020

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