Provider Demographics
NPI:1912275124
Name:DR OSVELIA G DEEDS LLC
Entity Type:Organization
Organization Name:DR OSVELIA G DEEDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALFACRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-352-5269
Mailing Address - Street 1:1542 ROSALBA ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-6552
Mailing Address - Country:US
Mailing Address - Phone:505-850-5314
Mailing Address - Fax:
Practice Address - Street 1:5203 JUAN TABO BLVD NE STE 2B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2691
Practice Address - Country:US
Practice Address - Phone:505-850-5314
Practice Address - Fax:505-221-5710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1095103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty