Basic Information
Provider Information | |||||||||
NPI: | 1124495841 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GONZALEZ | ||||||||
FirstName: | FRIDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HERRERA | ||||||||
OtherFirstName: | FRIDA | ||||||||
OtherMiddleName: | MARIA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 530 DEMOSS STREET | ||||||||
Address2: |   | ||||||||
City: | LORDSBURG | ||||||||
State: | NM | ||||||||
PostalCode: | 880452618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5755428384 | ||||||||
FaxNumber: | 5755422388 | ||||||||
Practice Location | |||||||||
Address1: | 1007 N POPE ST | ||||||||
Address2: |   | ||||||||
City: | SILVER CITY | ||||||||
State: | NM | ||||||||
PostalCode: | 880615161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5753881511 | ||||||||
FaxNumber: | 5753138236 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2015 | ||||||||
LastUpdateDate: | 02/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0175801 | NM | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.