MEDICARE: HIGH PLAINS NEUROPSYCHOLOGY ASSOCIATES PC

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	103G00000X	Clinical Neuropsychologist	761	NM

General Provider Information

NPI Number	:	1780916130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGH PLAINS NEUROPSYCHOLOGY ASSOCIATES PC

Provider Business Mailing Address
First Line	:	PO BOX 1705
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-1705
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 DOUGLAS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-3932
Country	:	US
Telephone Number	:	505-429-4679
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL NEUROPSYCHOLOGIST
Name	:	DR. GERALD RUSSELL
Credential	:
Telephone Number	:	505-429-4679

Provider Enumeration Date	:	02/10/2010
Last Update Date	:	03/11/2011

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