Provider Demographics
NPI:1538425541
Name:PEDIATRIC BEHAVIORAL MEDICINE, INC
Entity type:Organization
Organization Name:PEDIATRIC BEHAVIORAL MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-805-0849
Mailing Address - Street 1:2407 W PICACHO AVE
Mailing Address - Street 2:A104
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-4124
Mailing Address - Country:US
Mailing Address - Phone:575-805-0849
Mailing Address - Fax:575-541-3617
Practice Address - Street 1:2407 W PICACHO AVE
Practice Address - Street 2:A104
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-4124
Practice Address - Country:US
Practice Address - Phone:575-805-0849
Practice Address - Fax:575-541-3617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0370208000000X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty