Healthcare Provider Details

I. General information

NPI: 1417609058
Provider Name (Legal Business Name): GABRIELLE H EDIDIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 11TH ST NW
ALBUQUERQUE NM
87102-1898
US

IV. Provider business mailing address

9007 WASHINGTON ST NE
ALBUQUERQUE NM
87113-2722
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-4097
  • Fax:
Mailing address:
  • Phone: 505-690-4097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW-2026-0324
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: