Provider Demographics
NPI:1043415854
Name:BLACKGOAT, ELOUISE (COUNSELOR)
Entity Type:Individual
Prefix:MS
First Name:ELOUISE
Middle Name:
Last Name:BLACKGOAT
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W NIZHONI BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5766
Mailing Address - Country:US
Mailing Address - Phone:505-722-9470
Mailing Address - Fax:505-722-9570
Practice Address - Street 1:300 W NIZHONI BLVD STE A
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-722-9470
Practice Address - Fax:505-722-9570
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0122361101YA0400X, 101Y00000X
AZ11440101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)