Doctor Name: | GREGORY L. WILTFANG |
NPI Number: | 1265665848 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PHD, LISW |
License Number: | M-67045 |
Business Practice Address: | 139 S 2nd St Suite 4 Raton, NM - 877403905 |
Business Phone Number: | 5754452250 |
Business Fax Number: | 1575445054 |
Mailing Address: | P.o. Box 566, 139 S 2nd St RATON |
State: | NM |
Postal Code: | 877403905 |
Phone Number: | 5754452250 |
Fax Number: | 1575445054 |
NPI Enumeration Date: | 08/28/2009 |
NPI Last Update Date: | 11/21/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 1041C0700X |
License Number: | M-67045 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | NM |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Social Worker |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: | A social worker who holds a master |