1164506077 NPI number — ROBERT ANTHONY MACE SERRATORE LMHC MA

Table of content: ROBERT ANTHONY MACE SERRATORE LMHC MA (NPI 1164506077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164506077 NPI number — ROBERT ANTHONY MACE SERRATORE LMHC MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACE SERRATORE
Provider First Name:
ROBERT
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC MA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SERRATORE
Provider Other First Name:
ROBERTO
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164506077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10801 MANESS LN SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87121-3661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-693-2345
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 HOB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS LUNAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87031-7601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-865-3092
Provider Business Practice Location Address Fax Number:
505-865-7721
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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