Provider Demographics
NPI:1861033409
Name:GORDO, ANGEL R (LSAA)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:R
Last Name:GORDO
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 LA JOLLA LN
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5218
Mailing Address - Country:US
Mailing Address - Phone:505-947-3666
Mailing Address - Fax:
Practice Address - Street 1:72 GAIL HARRIS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-8116
Practice Address - Country:US
Practice Address - Phone:575-347-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0206891101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)