Provider Demographics
NPI:1609301142
Name:PELOQUIN, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PELOQUIN
Suffix:
Gender:M
Credentials:
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 37068
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-7068
Mailing Address - Country:US
Mailing Address - Phone:505-850-6072
Mailing Address - Fax:505-256-3600
Practice Address - Street 1:2425 SAN PEDRO DR NE
Practice Address - Street 2:SUIITE J
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4077
Practice Address - Country:US
Practice Address - Phone:505-850-6072
Practice Address - Fax:505-256-3600
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1181103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical