Healthcare Provider Details

I. General information

NPI: 1417591116
Provider Name (Legal Business Name): GEORGE GAMON CPSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 ANTHONY DR STE B
ANTHONY NM
88021-9366
US

IV. Provider business mailing address

PO BOX 584
CHAMBERINO NM
88027-0584
US

V. Phone/Fax

Practice location:
  • Phone: 585-619-0485
  • Fax:
Mailing address:
  • Phone: 575-619-0485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1011
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: