Healthcare Provider Details

I. General information

NPI: 1578506275
Provider Name (Legal Business Name): GABRIEL S CANDELARIA LBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 NORTH FIRST ST
GRANTS NM
87020
US

IV. Provider business mailing address

PO BOX 518
LOS LUNAS NM
87031
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-7985
  • Fax:
Mailing address:
  • Phone: 505-865-3350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberB-2568
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: