Provider Demographics
NPI:1760904882
Name:GETTIS, ELENA ALTAGRACIA
Entity Type:Individual
Prefix:MRS
First Name:ELENA
Middle Name:ALTAGRACIA
Last Name:GETTIS
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 1:1013 ARIZONA ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4827
Mailing Address - Country:US
Mailing Address - Phone:505-304-4087
Mailing Address - Fax:
Practice Address - Street 1:1013 ARIZONA ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4827
Practice Address - Country:US
Practice Address - Phone:505-304-4087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
510120264106S00000X
NM510120264106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM510120264OtherDRIVE LICENSE