Provider Demographics
NPI:1396879060
Name:SOUTHEASTERN NEW MEXICO SPEECH AND HEARING CLINIC
Entity type:Organization
Organization Name:SOUTHEASTERN NEW MEXICO SPEECH AND HEARING CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF AUDIOLOGY
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENGSTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:575-623-8474
Mailing Address - Street 1:1000 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3038
Mailing Address - Country:US
Mailing Address - Phone:575-623-8474
Mailing Address - Fax:575-623-8220
Practice Address - Street 1:1000 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3038
Practice Address - Country:US
Practice Address - Phone:575-623-8474
Practice Address - Fax:575-623-8220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3051237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54767Medicaid
NM3051OtherSTATE LICENSE NUMBER
NM54767Medicaid