Healthcare Provider Details

I. General information

NPI: 1295884153
Provider Name (Legal Business Name): ANDREW FELIPE GAMBOA PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 2ND ST SUITE 10
ROSWELL NM
88201-4670
US

IV. Provider business mailing address

PO BOX 2911
ROSWELL NM
88202-2911
US

V. Phone/Fax

Practice location:
  • Phone: 505-623-9322
  • Fax: 505-627-6339
Mailing address:
  • Phone: 505-420-0574
  • Fax: 505-627-6339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0598
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: