Healthcare Provider Details

I. General information

NPI: 1508233768
Provider Name (Legal Business Name): GERALD GARNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1737 VISTA DE COLINAS DR SE
RIO RANCHO NM
87124-4158
US

IV. Provider business mailing address

1737 VISTA DE COLINAS DR SE
RIO RANCHO NM
87124-4158
US

V. Phone/Fax

Practice location:
  • Phone: 505-270-3517
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1517
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: