Provider Demographics
NPI:1043382047
Name:CHAVEZ, GERALD ANTHONY (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ANTHONY
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4308 CARLISLE BLVD NE
Mailing Address - Street 2:STE 210
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4849
Mailing Address - Country:US
Mailing Address - Phone:505-247-1921
Mailing Address - Fax:505-247-1020
Practice Address - Street 1:4308 CARLISLE BLVD NE
Practice Address - Street 2:STE 210
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4849
Practice Address - Country:US
Practice Address - Phone:505-247-1921
Practice Address - Fax:505-247-1020
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1370103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81874359Medicaid