Healthcare Provider Details

I. General information

NPI: 1679836274
Provider Name (Legal Business Name): KARLA RUTH GANDIAGA PCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 FOOTHILL BLVD
ROCK SPRINGS WY
82901-5610
US

IV. Provider business mailing address

125 MAGNOLIA CIR
ROCK SPRINGS WY
82901-4378
US

V. Phone/Fax

Practice location:
  • Phone: 307-352-6677
  • Fax:
Mailing address:
  • Phone: 307-871-6239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPCSW-503
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: