Provider Demographics
NPI:1811348667
Name:MCDERMOTT, BIANCA ANTONIA (PHD)
Entity type:Individual
Prefix:DR
First Name:BIANCA
Middle Name:ANTONIA
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DUENDE ROAD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508
Mailing Address - Country:US
Mailing Address - Phone:505-221-4061
Mailing Address - Fax:505-465-0433
Practice Address - Street 1:10 TESUQUE ST
Practice Address - Street 2:
Practice Address - City:KEWA
Practice Address - State:NM
Practice Address - Zip Code:87052-9998
Practice Address - Country:US
Practice Address - Phone:505-221-4061
Practice Address - Fax:505-465-0433
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM745103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical