Provider Demographics
NPI:1528216694
Name:MEADOR, ALICE E (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:E
Last Name:MEADOR
Suffix:
Gender:F
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:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1359
Mailing Address - Country:US
Mailing Address - Phone:575-758-2919
Mailing Address - Fax:575-758-0262
Practice Address - Street 1:714 CALLE DON DIEGO
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3414
Practice Address - Country:US
Practice Address - Phone:505-367-3342
Practice Address - Fax:505-367-3361
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM374103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM374Medicaid