Healthcare Provider Details

I. General information

NPI: 1861098857
Provider Name (Legal Business Name): KITCHEN TABLE COUNSELING PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E JEFFERSON ST
GALLUP NM
87301-5113
US

IV. Provider business mailing address

333 E JEFFERSON ST
GALLUP NM
87301-5113
US

V. Phone/Fax

Practice location:
  • Phone: 360-433-7755
  • Fax:
Mailing address:
  • Phone: 360-433-7755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SANDRA GEARY
Title or Position: MEMBER
Credential: LCSW
Phone: 360-433-7755