PE GERARD WEIDEMAN, MS, MSW, LPCC, LADAC - NPI NUMBER 1639285638

Summary

Provider Name: PE GERARD WEIDEMAN, MS, MSW, LPCC, LADAC

NPI Number: 1639285638

Clasification: Counselor (101YA0400X)

Specialization: Addiction (Substance Use Disorder)

Address:
501 W PINE ST
DEMING, NM
ZIP 88030

Phone Number: (505) 541-1695



Detailed Information

Pe Gerard Weideman, MS, MSW, LPCC, LADAC is an addiction counselor in Deming, NM. The assigned NPI number for this provider is 1639285638 and is registered as an individual entity type.

The NPPES NPI record indicates the provider is a male.

The provider's business address is:

501 W PINE ST
DEMING, NM
ZIP 88030-530
Phone: (505) 541-1695
Fax: (505) 647-3033

The enumeration date for this NPI number is 8/22/2006 and was last updated on 4/18/2009.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 101YA0400X Counselor Addiction (Substance Use Disorder) 005438 NM No
2 101YM0800X Counselor Mental Health 005849 NM Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 A9813 MEDICAID NM

NPI Record

No. Field Name Field Value
1 NPI 1639285638
2 Entity Type Code 1
3 Provider Last Name Legal Name WEIDEMAN
4 Provider First Name PE GERARD
5 Provider Credential Text MS, MSW, LPCC, LADAC
6 Provider First Line Business Practice Location Address 501 W PINE ST
7 Provider Business Practice Location Address City Name DEMING
8 Provider Business Practice Location Address State Name NM
9 Provider Business Practice Location Address Postal Code 880303530
10 Provider Business Practice Location Address Country Code If outside U S US
11 Provider Business Practice Location Address Telephone Number 5055411695
12 Provider Business Practice Location Address Fax Number 5056473033
13 Provider Enumeration Date 8/22/2006
14 Last Update Date 4/18/2009
15 Provider Gender Code M
16 Healthcare Provider Taxonomy Code 1 101YA0400X
17 Provider License Number 1 005438
18 Provider License Number State Code 1 NM
19 Healthcare Provider Primary Taxonomy Switch 1 N
20 Healthcare Provider Taxonomy Code 2 101YM0800X
21 Provider License Number 2 005849
22 Provider License Number State Code 2 NM
23 Healthcare Provider Primary Taxonomy Switch 2 Y
24 Other Provider Identifier 1 A9813
25 Other Provider Identifier Type Code 1 05
26 Other Provider Identifier State 1 NM
27 Is Sole Proprietor N

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This page was last updated on: 12/10/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.