Provider Demographics
NPI:1417591116
Name:GAMON, GEORGE (CPSW)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:GAMON
Suffix:
Gender:M
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 584
Mailing Address - Street 2:
Mailing Address - City:CHAMBERINO
Mailing Address - State:NM
Mailing Address - Zip Code:88027-0584
Mailing Address - Country:US
Mailing Address - Phone:575-619-0485
Mailing Address - Fax:
Practice Address - Street 1:224 ANTHONY DR STE B
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021-9366
Practice Address - Country:US
Practice Address - Phone:585-619-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NM1011175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician