Basic Information
| Provider Information | |||||||||
| NPI: | 1760570170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAKOWSKI | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | YVONNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | ACOMA CANONCITO LAGUNA INDIAN HOSPITAL IHS DHHS | ||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525385 | ||||||||
| FaxNumber: | 5055525490 | ||||||||
| Practice Location | |||||||||
| Address1: | ACL HOSPITAL IHS DHHS | ||||||||
| Address2: | |||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525316 | ||||||||
| FaxNumber: | 5055525491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 368 | NM | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000N9923 | 05 | NM | MEDICAID |