1871591834 NPI number — KYLEE J GORDLEY-SHURTER LPCC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871591834 NPI number — KYLEE J GORDLEY-SHURTER LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDLEY-SHURTER
Provider First Name:
KYLEE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHURTER
Provider Other First Name:
KYLEE
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPCC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1871591834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2997
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORRALES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87048-2997
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-891-9581
Provider Business Mailing Address Fax Number:
505-867-5924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4686 CORRALES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORRALES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87048-8610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-891-9581
Provider Business Practice Location Address Fax Number:
505-867-5924
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  NM005691 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: NM00561 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NM600501 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: G2229 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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