Provider Demographics
NPI:1023106432
Name:BLEA JOHNSON, GLORIA J (LCSW)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:BLEA JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:J
Other - Last Name:BLEA JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 70112
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87197-0112
Mailing Address - Country:US
Mailing Address - Phone:505-259-1737
Mailing Address - Fax:505-448-7925
Practice Address - Street 1:PO BOX 70112
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87197-0112
Practice Address - Country:US
Practice Address - Phone:505-259-1737
Practice Address - Fax:505-448-7925
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-075441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49821342Medicaid
PHS000Medicare UPIN