Healthcare Provider Details

I. General information

NPI: 1285914119
Provider Name (Legal Business Name): KATHRYN REBECCA FORTUNE-GALLAGHER LMSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2623 BLUE HERON PL
LAS CRUCES NM
88011-4392
US

IV. Provider business mailing address

2623 BLUE HERON PL
LAS CRUCES NM
88011-4392
US

V. Phone/Fax

Practice location:
  • Phone: 734-260-3777
  • Fax: 999-999-9999
Mailing address:
  • Phone: 734-260-3777
  • Fax: 999-999-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number097803-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-0561.
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801067347
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: