Provider Demographics
NPI:1528603743
Name:CHILD PSYCHOLOGY CENTER
Entity Type:Organization
Organization Name:CHILD PSYCHOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH-WALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:662-603-1035
Mailing Address - Street 1:3751 N BUTLER AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6425
Mailing Address - Country:US
Mailing Address - Phone:662-603-1035
Mailing Address - Fax:
Practice Address - Street 1:3751 N BUTLER AVE STE 115
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6425
Practice Address - Country:US
Practice Address - Phone:662-603-1035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16970748Medicaid