Provider Demographics
NPI:1689060493
Name:ELIZABETH PENLAND PHD
Entity Type:Organization
Organization Name:ELIZABETH PENLAND PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:PENLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-896-3444
Mailing Address - Street 1:4011 BARBARA LOOP SE
Mailing Address - Street 2:STE 207
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1039
Mailing Address - Country:US
Mailing Address - Phone:505-896-3444
Mailing Address - Fax:505-994-9194
Practice Address - Street 1:4011 BARBARA LOOP SE
Practice Address - Street 2:STE 207
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1039
Practice Address - Country:US
Practice Address - Phone:505-896-3444
Practice Address - Fax:505-994-9194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0709103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM101550Medicaid
NMNMB2417OtherMEDICARE PTAN