Provider Demographics
NPI:1639302706
Name:GAFFORD, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GAFFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 S MAIN ST
Mailing Address - Street 2:BUILDING A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2974
Mailing Address - Country:US
Mailing Address - Phone:575-343-5644
Mailing Address - Fax:
Practice Address - Street 1:1065 S MAIN ST
Practice Address - Street 2:BUILDING A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2974
Practice Address - Country:US
Practice Address - Phone:575-343-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NM0158941101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No174400000XOther Service ProvidersSpecialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health