Individual
ELENA BETTOLIVAUGHAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD
Contact information
Practice address
1325 WYOMING BLVD NE, PMG KASEMAN BEHAVIORAL MEDICINE, ALBUQUERQUE, NM 87112-5046
(505) 291-2536
(505) 291-5327
Mailing address
PO BOX 26666, PHS PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-5356
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
103TP0814X
Psychoanalysis Psychologist
Primary
644
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000K2674
—
NM
Enumeration date
03/22/2007
Last updated
12/14/2009
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