Healthcare Provider Details

I. General information

NPI: 1013774025
Provider Name (Legal Business Name): MICAH GILMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA GILMER

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 W ZIA RD
SANTA FE NM
87505-5723
US

IV. Provider business mailing address

334 W ZIA RD
SANTA FE NM
87505-5723
US

V. Phone/Fax

Practice location:
  • Phone: 504-312-3794
  • Fax:
Mailing address:
  • Phone: 504-312-3794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0020879
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: