Provider Demographics
NPI:1063627354
Name:JIM, LEROY (LPCC, CRC)
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:JIM
Suffix:
Gender:M
Credentials:LPCC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 E AZTEC AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4803
Mailing Address - Country:US
Mailing Address - Phone:505-863-3828
Mailing Address - Fax:
Practice Address - Street 1:2025 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4803
Practice Address - Country:US
Practice Address - Phone:505-863-3828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00056257225C00000X
NM0146941101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM43929842Medicaid
NM76986063Medicaid