Healthcare Provider Details

I. General information

NPI: 1487734315
Provider Name (Legal Business Name): GABRIEL I RAEL LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH ROAD
ISLETA NM
87022-0000
US

IV. Provider business mailing address

PO BOX 640
ISLETA NM
87022-0640
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-4863
  • Fax: 505-869-4881
Mailing address:
  • Phone: 505-869-4863
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH3520
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: