Healthcare Provider Details

I. General information

NPI: 1104286103
Provider Name (Legal Business Name): SHELBI RHEA GORET LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 FIVE POINTS RD SW
ALBUQUERQUE NM
87105-3179
US

IV. Provider business mailing address

9250 EAGLE RANCH RD NW APT 1723
ALBUQUERQUE NM
87114-6033
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-9619
  • Fax:
Mailing address:
  • Phone: 575-418-7712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0172751
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: