Provider Demographics
NPI:1861824898
Name:SANDIA NEUROPSYCHOLOGY LLC
Entity Type:Organization
Organization Name:SANDIA NEUROPSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:THOMA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-270-4242
Mailing Address - Street 1:3400 CONSTITUTION NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:505-270-4242
Mailing Address - Fax:505-288-3579
Practice Address - Street 1:3400 CONSTITUTION NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-270-4242
Practice Address - Fax:505-288-3579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0796103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty