Provider Demographics
NPI:1316982705
Name:GATES-CRANDALL, TREVOR G
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:G
Last Name:GATES-CRANDALL
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:TREVOR
Other - Middle Name:G
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, LCSW
Mailing Address - Street 1:1200 GRETTA ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-5556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2050A 2ND ST SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-2300
Practice Address - Country:US
Practice Address - Phone:817-825-7662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27722101YA0400X
NY730803441041C0700X
COCSW.099272111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)