=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639285638
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PE GERARD WEIDEMAN MS, MSW, LPCC, LADAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 04/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 W PINE ST
-----------------------------------------------------
City | DEMING
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88030-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-541-1695
-----------------------------------------------------
Fax | 505-647-3033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1747
-----------------------------------------------------
City | MESILLA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88046-1747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-541-1695
-----------------------------------------------------
Fax | 505-647-3033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 005438
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 005849
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------