MEDICARE: GUSTAVO GARAY-VIDAL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SWB-2022-0049	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750660346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUSTAVO GARAY-VIDAL LCSW

Provider Business Mailing Address
First Line	:	5616 W VALLEY CIR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79932-1900
Country	:	US
Telephone Number	:	915-373-1294
Fax Number	:

Provider Business Practice Location Address
First Line	:	5616 W VALLEY CIR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79932-1900
Country	:	US
Telephone Number	:	915-373-1294
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2011
Last Update Date	:	11/22/2024

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