Provider Demographics
NPI:1477862662
Name:TRUJILLO, AMY J (EDS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:TRUJILLO
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88023
Mailing Address - Country:US
Mailing Address - Phone:575-537-4000
Mailing Address - Fax:575-537-3921
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023
Practice Address - Country:US
Practice Address - Phone:575-537-4000
Practice Address - Fax:575-537-3921
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM334946103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool