Provider Demographics
NPI:1538372479
Name:GRANADOS, TOMAS REFUGIO (PSYD)
Entity type:Individual
Prefix:DR
First Name:TOMAS
Middle Name:REFUGIO
Last Name:GRANADOS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93874
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-3874
Mailing Address - Country:US
Mailing Address - Phone:505-797-0810
Mailing Address - Fax:505-797-0814
Practice Address - Street 1:7000 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4313
Practice Address - Country:US
Practice Address - Phone:505-797-0810
Practice Address - Fax:505-797-0814
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM702103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00JP49OtherCLINICAL PSYCHOLOGY
NMS8524Medicaid
NM201011548OtherCLINICAL PSYCHOLOGY
NM343531300Medicare PIN