Basic Information
| Provider Information | |||||||||
| NPI: | 1831354620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEER OAKS SOUTHWEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7272 WURZBACH RD | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153472 | ||||||||
| FaxNumber: | 2105939863 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 SAN PEDRO DR NE | ||||||||
| Address2: | SUITE 222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871106724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052543505 | ||||||||
| FaxNumber: | 2105939863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 02/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOSKIND | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2106153472 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 382270 | 05 | AZ | MEDICAID |