Healthcare Provider Details

I. General information

NPI: 1043863442
Provider Name (Legal Business Name): GABRIEL C CORDOVA LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 LOMAS BLVD NW
ALBUQUERQUE NM
87102-2080
US

IV. Provider business mailing address

1321 E POPLAR ST
DEMING NM
88030-4807
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-1701
  • Fax: 505-247-1704
Mailing address:
  • Phone: 575-546-5951
  • Fax: 575-546-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM-10436
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: