Individual
LEROY JIM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LPCC, CRC
Contact information
Practice address
2025 E AZTEC AVE, GALLUP, NM 87301-4803
(505) 863-3828
Mailing address
2025 E AZTEC AVE, GALLUP, NM 87301-4803
(505) 863-3828
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
0146941
NM
225C00000X
Rehabilitation Counselor
00056257
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
43929842
—
NM
05
—
76986063
—
NM
Enumeration date
05/11/2007
Last updated
06/15/2016
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