Individual
DR. MINDY JITMANOWAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PSY
Contact information
Practice address
8300 CONSTITUTION AVE NE, BLDG D, ALBUQUERQUE, NM 87110-7613
(505) 291-2402
Mailing address
PO BOX 26666, PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
PSY1623
NM
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
09/06/2013
Last updated
05/20/2021
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