NPIMap

Organization Active NPI

Meditelecare of New Mexico, LLC

  • Psychiatry Physician
  • Espanola, NM
National Provider Identifier
1629639729
Registry record updated May 5, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
MEDITELECARE OF NEW MEXICO, LLC
Practice address
206 S Coronado Ave
Espanola, NM 87532-2792
Phone
(860) 788-6404
NPI assigned
Jun 28, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 5, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Andrea Godfrey
Title
Credentialing & Enrollment Manager
Phone
(860) 398-6441

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X Primary
Geriatric Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0805X
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X

Addresses

Primary practice location

206 S Coronado Ave
Espanola, NM 87532-2792

Mailing address

PO Box 1595
Middletown, CT 06457-8095
Phone (860) 788-6404

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NM

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190815000690 NM Part B Supplier - Clinic/Group Practice 1254668122 Receives reassigned benefits from 17 practitioners
Practice locations: Espanola, NM

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1561680000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746403200000",
    "number": "1629639729",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1595",
            "city": "MIDDLETOWN",
            "state": "CT",
            "postal_code": "064578095",
            "telephone_number": "860-788-6404",
            "fax_number": "860-829-0495"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "206 S CORONADO AVE",
            "city": "ESPANOLA",
            "state": "NM",
            "postal_code": "875322792",
            "telephone_number": "860-788-6404"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDITELECARE OF NEW MEXICO, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-06-28",
        "last_updated": "2025-05-05",
        "certification_date": "2025-05-05",
        "status": "A",
        "authorized_official_last_name": "GODFREY",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_title_or_position": "CREDENTIALING & ENROLLMENT MANAGER",
        "authorized_official_telephone_number": "860-398-6441"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2084P0805X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Geriatric Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Espanola, NM

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 5, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.