Provider Demographics
NPI:1730237975
Name:BECKER, GRETCHEN LAURA
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:LAURA
Last Name:BECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8113 KRIM DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5223
Mailing Address - Country:US
Mailing Address - Phone:505-797-9392
Mailing Address - Fax:
Practice Address - Street 1:4505 BALI CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2801
Practice Address - Country:US
Practice Address - Phone:505-292-7104
Practice Address - Fax:505-296-2183
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMG7777235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG7777Medicaid