Healthcare Provider Details

I. General information

NPI: 1730117649
Provider Name (Legal Business Name): GARY HARMON PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1096 MECHEM DR SUITE 203
RUIDOSO NM
88345-7067
US

IV. Provider business mailing address

PO BOX 175 HWY 37 NM10
NOGAL NM
88341-0175
US

V. Phone/Fax

Practice location:
  • Phone: 505-258-4708
  • Fax: 505-258-2678
Mailing address:
  • Phone: 505-258-4708
  • Fax: 505-258-3678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number479
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: