Provider Demographics
NPI:1457386963
Name:ROTH-WALL, PRISCILLA (PHD)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:ROTH-WALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3751 N BUTLER AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6425
Mailing Address - Country:US
Mailing Address - Phone:505-787-2640
Mailing Address - Fax:505-787-2789
Practice Address - Street 1:3751 N BUTLER AVE STE 115
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6425
Practice Address - Country:US
Practice Address - Phone:505-787-2640
Practice Address - Fax:505-787-2789
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPSY1470103TC2200X, 103TM1800X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPSY1470OtherPSYCHOLOGY LICENSE
NM16970748Medicaid
NM73763700OtherMAGELLAN
MS680000254Medicare ID - Type Unspecified
MS00126978Medicaid