Healthcare Provider Details

I. General information

NPI: 1841460664
Provider Name (Legal Business Name): FAE M EPALOOSE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 E AZTEC AVE
GALLUP NM
87301-4803
US

IV. Provider business mailing address

2025 E AZTEC AVE
GALLUP NM
87301-4803
US

V. Phone/Fax

Practice location:
  • Phone: 505-633-8288
  • Fax: 505-443-4345
Mailing address:
  • Phone: 58-633-8285
  • Fax: 505-443-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0135721
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: