Provider Demographics
NPI:1821370842
Name:PSYCHOLOGICAL ASSESSMENT & TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL ASSESSMENT & TREATMENT CENTER, LLC
Other - Org Name:CORRALES PSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-440-3595
Mailing Address - Street 1:4313 CORRALES RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8663
Mailing Address - Country:US
Mailing Address - Phone:505-440-3595
Mailing Address - Fax:855-690-6884
Practice Address - Street 1:4313 CORRALES RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8663
Practice Address - Country:US
Practice Address - Phone:505-440-3595
Practice Address - Fax:855-690-6884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM757103G00000X, 103TB0200X, 103TC0700X, 103TC2200X, 103TS0200X
NM333103TB0200X, 103TC0700X, 103TC2200X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty