Provider Demographics
NPI:1205995503
Name:GILSDORF, RICHARD PAUL (LPCC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:PAUL
Last Name:GILSDORF
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-7834
Mailing Address - Country:US
Mailing Address - Phone:575-443-6166
Mailing Address - Fax:575-437-0755
Practice Address - Street 1:1301 OREGON AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5710
Practice Address - Country:US
Practice Address - Phone:575-443-6166
Practice Address - Fax:575-437-0755
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0139331101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84079576Medicaid