Healthcare Provider Details

I. General information

NPI: 1639302706
Provider Name (Legal Business Name): BRIAN GAFFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 S MAIN ST BUILDING A
LAS CRUCES NM
88005-2974
US

IV. Provider business mailing address

1065 S MAIN ST BUILDING A
LAS CRUCES NM
88005-2974
US

V. Phone/Fax

Practice location:
  • Phone: 575-343-5644
  • Fax:
Mailing address:
  • Phone: 575-343-5644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0158941
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0158941
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: