Provider Demographics
NPI:1528577723
Name:GOSSETT, REBBECCA JO
Entity Type:Individual
Prefix:
First Name:REBBECCA
Middle Name:JO
Last Name:GOSSETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 COLORADO DR
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-7028
Mailing Address - Country:US
Mailing Address - Phone:575-607-5588
Mailing Address - Fax:
Practice Address - Street 1:620 W 2ND ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6246
Practice Address - Country:US
Practice Address - Phone:575-607-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0161891101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health