Provider Demographics
NPI:1316391063
Name:NORTH STAR PSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:NORTH STAR PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-412-7756
Mailing Address - Street 1:1475 CENTRAL AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3160
Mailing Address - Country:US
Mailing Address - Phone:505-412-7756
Mailing Address - Fax:
Practice Address - Street 1:1475 CENTRAL AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3160
Practice Address - Country:US
Practice Address - Phone:505-412-7756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-19
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0168791101YM0800X
NM688103TP0016X
NMMD2013-06592084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM67620752Medicaid