Healthcare Provider Details

I. General information

NPI: 1386558484
Provider Name (Legal Business Name): AMY BALDONADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 PARK AVE
GALLUP NM
87301-5806
US

IV. Provider business mailing address

601 EDITH AVE
GALLUP NM
87301-5670
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-8922
  • Fax:
Mailing address:
  • Phone: 575-642-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number292322
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: