Healthcare Provider Details

I. General information

NPI: 1760024822
Provider Name (Legal Business Name): GARY L FIELD LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 STAAB ST
SANTA FE NM
87501-1844
US

IV. Provider business mailing address

317 STAAB ST
SANTA FE NM
87501-1844
US

V. Phone/Fax

Practice location:
  • Phone: 505-910-0033
  • Fax:
Mailing address:
  • Phone: 505-910-0033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10924
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: