Provider Demographics
NPI:1205843265
Name:PEDROTTY, MARK HENRY (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HENRY
Last Name:PEDROTTY
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 1:3029 DELANO PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2034
Mailing Address - Country:US
Mailing Address - Phone:505-688-0601
Mailing Address - Fax:
Practice Address - Street 1:3200 CARLISLE BLVD NE STE 224
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1664
Practice Address - Country:US
Practice Address - Phone:505-688-0601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM732103TC0700X, 103TR0400X, 103T00000X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty