Provider Demographics
NPI:1104557420
Name:LINDBERG, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:LINDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 VALENTINO ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3597
Mailing Address - Country:US
Mailing Address - Phone:505-688-9920
Mailing Address - Fax:
Practice Address - Street 1:7850 JEFFERSON ST NE STE 300
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4314
Practice Address - Country:US
Practice Address - Phone:505-884-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0186291101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)