Healthcare Provider Details

I. General information

NPI: 1114979275
Provider Name (Legal Business Name): GARY D LONGANECKER LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 WALNUT STREET OFFICE B
CLAYTON NM
88415
US

IV. Provider business mailing address

509 MAIN ST
CLAYTON NM
88415-2921
US

V. Phone/Fax

Practice location:
  • Phone: 505-374-2032
  • Fax: 505-374-0158
Mailing address:
  • Phone: 505-374-9830
  • Fax: 505-374-0158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1573
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: