Provider Demographics
NPI:1831529445
Name:GENDUSO, AUDRA (LMT)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:GENDUSO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:
Other - Last Name:GENDUSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT, LMHC
Mailing Address - Street 1:8 GRAYHAWK PL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1332
Mailing Address - Country:US
Mailing Address - Phone:505-690-6679
Mailing Address - Fax:
Practice Address - Street 1:1800 OLD PECOS TRL STE B
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4787
Practice Address - Country:US
Practice Address - Phone:505-690-6679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMH0216981101YM0800X
NM4830171W00000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor