Provider Demographics
NPI:1871591834
Name:GORDLEY-SHURTER, KYLEE J (LPCC)
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:J
Last Name:GORDLEY-SHURTER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:KYLEE
Other - Middle Name:J
Other - Last Name:SHURTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC
Mailing Address - Street 1:PO BOX 2997
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-2997
Mailing Address - Country:US
Mailing Address - Phone:505-891-9581
Mailing Address - Fax:505-867-5924
Practice Address - Street 1:4686 CORRALES RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8610
Practice Address - Country:US
Practice Address - Phone:505-891-9581
Practice Address - Fax:505-867-5924
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM005691101YP2500X
NMNM00561101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM600501Medicaid
NMG2229Medicaid