Provider Demographics
NPI:1023773876
Name:GALLANT MENTAL HEALTH LLC
Entity type:Organization
Organization Name:GALLANT MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN, PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:IDOWU
Authorized Official - Middle Name:M
Authorized Official - Last Name:AWOSERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-225-7122
Mailing Address - Street 1:6565 AMERICAS PKWY NE STE 200
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-8172
Mailing Address - Country:US
Mailing Address - Phone:505-225-7122
Mailing Address - Fax:505-225-7188
Practice Address - Street 1:6565 AMERICAS PKWY NE STE 200
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-8172
Practice Address - Country:US
Practice Address - Phone:505-225-7122
Practice Address - Fax:505-225-7188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-07
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty