Healthcare Provider Details

I. General information

NPI: 1265665848
Provider Name (Legal Business Name): GREGORY L. WILTFANG PHD, LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 S 2ND ST SUITE 4
RATON NM
87740-3905
US

IV. Provider business mailing address

P.O. BOX 566 139 S 2ND ST
RATON NM
87740-3905
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-2250
  • Fax: 157-544-5054
Mailing address:
  • Phone: 575-445-2250
  • Fax: 157-544-5054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-67045
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07762
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: