Healthcare Provider Details

I. General information

NPI: 1144373564
Provider Name (Legal Business Name): LESLIE A GILL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 FLOYD GOLDEN CIR
PORTALES NM
88130-7031
US

IV. Provider business mailing address

212 FLOYD GOLDEN CIR
PORTALES NM
88130-7031
US

V. Phone/Fax

Practice location:
  • Phone: 505-799-3553
  • Fax:
Mailing address:
  • Phone: 505-799-3553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number299606
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: