Provider Demographics
NPI:1114979275
Name:LONGANECKER, GARY D (LPCC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:D
Last Name:LONGANECKER
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 1:509 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NM
Mailing Address - Zip Code:88415-2921
Mailing Address - Country:US
Mailing Address - Phone:505-374-9830
Mailing Address - Fax:505-374-0158
Practice Address - Street 1:110 WALNUT STREET
Practice Address - Street 2:OFFICE B
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415
Practice Address - Country:US
Practice Address - Phone:505-374-2032
Practice Address - Fax:505-374-0158
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1573101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM95071881Medicaid