Basic Information
| Provider Information | |||||||||
| NPI: | 1154877371 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | J. MICHAEL MASH PRESCRIBING PSYCHOLOGIST LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94508 | ||||||||
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| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871994508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4155 STATE ROAD 68 | ||||||||
| Address2: | UNIT 6 | ||||||||
| City: | RANCHO DE TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757767432 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2016 | ||||||||
| LastUpdateDate: | 08/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | MASH | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PH.D. | ||||||||
| AuthorizedOfficialTelephone: | 5757767432 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP0016X | 609 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
No ID Information.