Provider Demographics
NPI:1003420696
Name:GALL, HEIDI MAE (LMHC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MAE
Last Name:GALL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 CAMINO SANTA ANA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3683
Mailing Address - Country:US
Mailing Address - Phone:505-303-8825
Mailing Address - Fax:
Practice Address - Street 1:2504 CAMINO ENTRADA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4851
Practice Address - Country:US
Practice Address - Phone:505-471-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0212831101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty