Healthcare Provider Details

I. General information

NPI: 1700167103
Provider Name (Legal Business Name): JOSHUA RAYMOND GALLOUPE LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SUNSET LOOP
MESCALERO NM
88340
US

IV. Provider business mailing address

407B OLD MESCALERO RD # B
TULAROSA NM
88352-2480
US

V. Phone/Fax

Practice location:
  • Phone: 575-464-4432
  • Fax: 575-464-4331
Mailing address:
  • Phone: 702-406-5541
  • Fax: 575-464-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2025-0903
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: