Provider Demographics
NPI:1639385339
Name:LOUIS, ROBERT J II (MA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:LOUIS
Suffix:II
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 BURKE DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5461
Mailing Address - Country:US
Mailing Address - Phone:505-979-6102
Mailing Address - Fax:505-863-6103
Practice Address - Street 1:310 E MESA AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6147
Practice Address - Country:US
Practice Address - Phone:505-979-6102
Practice Address - Fax:505-863-6103
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0118711101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM19683537Medicaid