Provider Demographics
NPI:1396093167
Name:WACHS, GRETCHEN (LPCC)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:WACHS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.611
Mailing Address - Street 2:
Mailing Address - City:TESUQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87574
Mailing Address - Country:US
Mailing Address - Phone:505-501-0962
Mailing Address - Fax:
Practice Address - Street 1:1532 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3512
Practice Address - Country:US
Practice Address - Phone:505-490-5653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0163211101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44737874Medicaid