Basic Information
| Provider Information | |||||||||
| NPI: | 1598019358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF NEW MEXICO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE STE 2222 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 SILVER AVE SW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059257600 | ||||||||
| FaxNumber: | 5059257601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2012 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | MCGRATH | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5059257600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | M-07057 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.