Provider Demographics
NPI:1457452971
Name:NEW MEXICO STATE UNIVERSITY SPEECH AND HEARING CENTER
Entity Type:Organization
Organization Name:NEW MEXICO STATE UNIVERSITY SPEECH AND HEARING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR OF CD PROGRAM
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CCC-SLP
Authorized Official - Phone:505-646-2364
Mailing Address - Street 1:PO BOX 30001
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88003-8001
Mailing Address - Country:US
Mailing Address - Phone:505-646-3906
Mailing Address - Fax:505-646-3140
Practice Address - Street 1:CORNER OF UNIVERSITY AND JORDAN
Practice Address - Street 2:SPEECH BLDG. ROOM 158
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88003-8001
Practice Address - Country:US
Practice Address - Phone:505-646-3906
Practice Address - Fax:505-646-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6545231H00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML3211Medicaid
NM326547Medicare ID - Type Unspecified