Provider Demographics
NPI:1487735965
Name:HOLSTEAD, BOBBY N (PHD)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:N
Last Name:HOLSTEAD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 FAIRWAY RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5720
Mailing Address - Country:US
Mailing Address - Phone:505-379-0734
Mailing Address - Fax:
Practice Address - Street 1:2050A 2ND ST SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-5103
Practice Address - Country:US
Practice Address - Phone:505-846-3200
Practice Address - Fax:575-784-6028
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM214103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00NM00N890OtherBC/BS OF NM
NMN6176Medicaid
NM201004465OtherPRESBYTERIAN HEALTH PLAN
NMR13308Medicare UPIN
NM2507349Medicare ID - Type Unspecified
NMN6176Medicaid