Healthcare Provider Details

I. General information

NPI: 1639285638
Provider Name (Legal Business Name): PE GERARD WEIDEMAN MS, MSW, LPCC, LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 04/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W PINE ST
DEMING NM
88030-3530
US

IV. Provider business mailing address

PO BOX 1747
MESILLA NM
88046-1747
US

V. Phone/Fax

Practice location:
  • Phone: 505-541-1695
  • Fax: 505-647-3033
Mailing address:
  • Phone: 505-541-1695
  • Fax: 505-647-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number005438
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005849
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: