Provider Demographics
NPI:1134278179
Name:MASTELLONE, MAX (PHD)
Entity type:Individual
Prefix:DR
First Name:MAX
Middle Name:
Last Name:MASTELLONE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 CASHMERE CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-0800
Mailing Address - Country:US
Mailing Address - Phone:609-706-5931
Mailing Address - Fax:505-521-6259
Practice Address - Street 1:330 N CAMPO ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3433
Practice Address - Country:US
Practice Address - Phone:609-706-5931
Practice Address - Fax:505-521-6259
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0953103TC0700X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39980847Medicaid
NM22559302Medicaid