Healthcare Provider Details

I. General information

NPI: 1679638738
Provider Name (Legal Business Name): SALLY RAE GOBLE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 PASEO DE SAN ANTONIO
PLACITAS NM
87043-8735
US

IV. Provider business mailing address

PO BOX 235
PLACITAS NM
87043-0235
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-0846
  • Fax: 505-404-8062
Mailing address:
  • Phone: 505-660-0846
  • Fax: 505-404-8062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number203
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0107651
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: