Provider Demographics
NPI:1215354188
Name:HALLFORD, GARRY
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:
Last Name:HALLFORD
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:PO BOX 7065
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87194-7065
Mailing Address - Country:US
Mailing Address - Phone:505-243-2223
Mailing Address - Fax:
Practice Address - Street 1:803 TIJERAS AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3096
Practice Address - Country:US
Practice Address - Phone:505-243-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0170041101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1164633541OtherNPI
NM87177056Medicaid