Provider Demographics
NPI:1861606246
Name:TOMAS R. GRANADOS, PSY.D.
Entity type:Organization
Organization Name:TOMAS R. GRANADOS, PSY.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOMAS
Authorized Official - Middle Name:REFUGIO
Authorized Official - Last Name:GRANADOS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:505-797-0810
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM702103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201011548OtherCLINICAL PSYCHOLOGY
NMS8524Medicaid
NMNM00JP49OtherCLINICAL PSYCHOLOGY
NMS8524Medicaid