Healthcare Provider Details

I. General information

NPI: 1902932627
Provider Name (Legal Business Name): KRISTEN B. GORBACH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 W DELGADO AVE
BELEN NM
87002-2805
US

IV. Provider business mailing address

35 SCHULTZ LANE
BELEN NM
87002
US

V. Phone/Fax

Practice location:
  • Phone: 505-966-1343
  • Fax: 505-966-1350
Mailing address:
  • Phone: 505-966-1343
  • Fax: 505-966-1350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1524
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: