Healthcare Provider Details

I. General information

NPI: 1154848109
Provider Name (Legal Business Name): AGNES GARLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 SALIDA DEL SOL
LOS LUNAS NM
87031-8807
US

IV. Provider business mailing address

19 SALIDA DEL SOL
LOS LUNAS NM
87031-8807
US

V. Phone/Fax

Practice location:
  • Phone: 505-835-9640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: