1174778252 NPI number — MONIKA SANDBERG PETERSON PH.D.

Table of content: MONIKA SANDBERG PETERSON PH.D. (NPI 1174778252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174778252 NPI number — MONIKA SANDBERG PETERSON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
MONIKA
Provider Middle Name:
SANDBERG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANDBERG
Provider Other First Name:
MONIKA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174778252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 45824
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO RANCHO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87174-5824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-350-7160
Provider Business Mailing Address Fax Number:
505-884-5701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 GRANDE BLVD. SE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-1655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-350-7160
Provider Business Practice Location Address Fax Number:
505-884-5701
Provider Enumeration Date:
11/17/2008

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 , with the licence number:  0121881 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 1093 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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