Individual
PRISCILLA ROTH-WALL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
3751 N BUTLER AVE STE 115, FARMINGTON, NM 87401-6425
(505) 787-2640
(505) 787-2789
Mailing address
3751 N BUTLER AVE STE 115, FARMINGTON, NM 87401-6425
(505) 787-2640
(505) 787-2789
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
PSY1470
NM
103TC2200X
Clinical Child & Adolescent Psychologist
PSY1470
NM
103TM1800X
Intellectual & Developmental Disabilities Psychologist
PSY1470
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
16970748
—
NM
01
—
73763700
MAGELLAN
NM
01
—
PSY1470
PSYCHOLOGY LICENSE
NM
Enumeration date
07/12/2006
Last updated
04/30/2020
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