Healthcare Provider Details

I. General information

NPI: 1639385339
Provider Name (Legal Business Name): ROBERT J LOUIS II M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E MESA AVE
GALLUP NM
87301-6147
US

IV. Provider business mailing address

503 BURKE DR
GALLUP NM
87301-5461
US

V. Phone/Fax

Practice location:
  • Phone: 505-979-6102
  • Fax: 505-863-6103
Mailing address:
  • Phone: 505-979-6102
  • Fax: 505-863-6103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0118711
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: