Provider Demographics
NPI:1063889715
Name:LUJAN-GANTZ, AUDREY MAY (BCBA)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:MAY
Last Name:LUJAN-GANTZ
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 PASADENA AVE NE UNIT F
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2208
Mailing Address - Country:US
Mailing Address - Phone:505-856-6880
Mailing Address - Fax:
Practice Address - Street 1:5200 PASADENA AVE NE UNIT F
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2208
Practice Address - Country:US
Practice Address - Phone:505-856-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2677103K00000X
1-22-58035103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst