Provider Demographics
NPI:1750660346
Name:GARAY-VIDAL, GUSTAVO (LMSW)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:GARAY-VIDAL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7760 ALABAMA ST.
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-3136
Mailing Address - Country:US
Mailing Address - Phone:915-757-7999
Mailing Address - Fax:915-757-8004
Practice Address - Street 1:7760 ALABAMA ST.
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904-3136
Practice Address - Country:US
Practice Address - Phone:915-757-7999
Practice Address - Fax:915-757-8004
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60458104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid