Provider Demographics
NPI:1659403293
Name:ROYBAL, BERNADETTE (MS, CCC-SP)
Entity Type:Individual
Prefix:MS
First Name:BERNADETTE
Middle Name:
Last Name:ROYBAL
Suffix:
Gender:F
Credentials:MS, CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 VIA CABALLERO DEL NORT
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6527
Mailing Address - Country:US
Mailing Address - Phone:505-467-3221
Mailing Address - Fax:
Practice Address - Street 1:1300 CAMINO SIERRA VIS
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1007
Practice Address - Country:US
Practice Address - Phone:505-467-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH7246Medicaid