Healthcare Provider Details

I. General information

NPI: 1144523200
Provider Name (Legal Business Name): GISELLE DEL CARMEN BANGO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2554 SHAVANO PEAK DR NE
RIO RANCHO NM
87144-6792
US

IV. Provider business mailing address

2554 SHAVANO PEAK DR NE
RIO RANCHO NM
87144-6792
US

V. Phone/Fax

Practice location:
  • Phone: 828-301-8171
  • Fax: 828-333-5584
Mailing address:
  • Phone: 828-301-8171
  • Fax: 828-333-5584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0212061
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1409
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberCMF0201891
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: