Healthcare Provider Details

I. General information

NPI: 1023773876
Provider Name (Legal Business Name): GALLANT MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2021
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 AMERICAS PKWY NE STE 200
ALBUQUERQUE NM
87110-8172
US

IV. Provider business mailing address

6565 AMERICAS PKWY NE STE 200
ALBUQUERQUE NM
87110-8172
US

V. Phone/Fax

Practice location:
  • Phone: 505-225-7122
  • Fax: 505-225-7188
Mailing address:
  • Phone: 505-225-7122
  • Fax: 505-225-7188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IDOWU M AWOSERE
Title or Position: APRN, PMHNP-BC
Credential:
Phone: 505-225-7122