Provider Demographics
NPI:1326115049
Name:NEUROPSYCHOLOGICAL SERVICES OF NEW MEXICO, LLC
Entity Type:Organization
Organization Name:NEUROPSYCHOLOGICAL SERVICES OF NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-404-9395
Mailing Address - Street 1:10110 SPAIN RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1965
Mailing Address - Country:US
Mailing Address - Phone:505-404-9395
Mailing Address - Fax:505-299-4740
Practice Address - Street 1:10110 SPAIN RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1965
Practice Address - Country:US
Practice Address - Phone:505-404-9395
Practice Address - Fax:505-299-4740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0969103G00000X, 103TC0700X
103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty