Basic Information
| Provider Information | |||||||||
| NPI: | 1619298585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLARDO NEYRA | ||||||||
| FirstName: | MARIA DEL ROSARIO | ||||||||
| MiddleName: | JOSEFINA | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2551 COORS BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053383320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 541 QUANTUM RD NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871244502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059949178 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2010 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0128851 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 10 | 01 | NM | HEALTH CARE PROVIDER TAXONOMY | OTHER | 18576028 | 05 | NM | MEDICAID |