Provider Demographics
NPI:1104578319
Name:MIMBRES PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:MIMBRES PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITTAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-358-0087
Mailing Address - Street 1:2811 INDIAN SCHOOL RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1825
Mailing Address - Country:US
Mailing Address - Phone:505-358-0087
Mailing Address - Fax:
Practice Address - Street 1:2811 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1825
Practice Address - Country:US
Practice Address - Phone:505-358-0087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health