Provider Demographics
NPI:1265665848
Name:WILTFANG, GREGORY L (PHD, LISW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:WILTFANG
Suffix:
Gender:M
Credentials:PHD, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 566
Mailing Address - Street 2:139 S 2ND ST
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-3905
Mailing Address - Country:US
Mailing Address - Phone:575-445-2250
Mailing Address - Fax:157-544-5054
Practice Address - Street 1:139 S 2ND ST
Practice Address - Street 2:SUITE 4
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-3905
Practice Address - Country:US
Practice Address - Phone:575-445-2250
Practice Address - Fax:157-544-5054
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-670451041C0700X
NMI-077621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical