Provider Demographics
NPI:1619157203
Name:ATANASOFF, GWENN (OT)
Entity Type:Individual
Prefix:
First Name:GWENN
Middle Name:
Last Name:ATANASOFF
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 SUNSHINE TER SE
Mailing Address - Street 2:LOWELL ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-3906
Mailing Address - Country:US
Mailing Address - Phone:505-764-2011
Mailing Address - Fax:
Practice Address - Street 1:1700 SUNSHINE TER SE
Practice Address - Street 2:LOWELL ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3906
Practice Address - Country:US
Practice Address - Phone:505-764-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1951225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM82787808Medicaid