Provider Demographics
NPI:1174909964
Name:A PORT IN A STORM
Entity type:Organization
Organization Name:A PORT IN A STORM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAGE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASTOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:575-737-9352
Mailing Address - Street 1:1337 GUSDORF RD STE H
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6297
Mailing Address - Country:US
Mailing Address - Phone:575-737-9352
Mailing Address - Fax:575-737-5054
Practice Address - Street 1:1337 GUSDORF RD STE H
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6297
Practice Address - Country:US
Practice Address - Phone:575-737-9352
Practice Address - Fax:575-737-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0858103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM331413405Medicare PIN