Healthcare Provider Details

I. General information

NPI: 1265500151
Provider Name (Legal Business Name): KENNETH GILMAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 GUADALUPE TRL NW
ALBUQUERQUE NM
87107-3346
US

IV. Provider business mailing address

4801 LANG AVE NE SUITE 110
ALBUQUERQUE NM
87109-4475
US

V. Phone/Fax

Practice location:
  • Phone: 505-980-1865
  • Fax:
Mailing address:
  • Phone: 505-980-1865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0837
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: