Provider Demographics
NPI:1265500151
Name:GILMAN, KENNETH (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GILMAN
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 1:4801 LANG AVE NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4475
Mailing Address - Country:US
Mailing Address - Phone:505-980-1865
Mailing Address - Fax:
Practice Address - Street 1:5219 GUADALUPE TRL NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-3346
Practice Address - Country:US
Practice Address - Phone:505-980-1865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0837103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46181334Medicaid