Basic Information
Provider Information | |||||||||
NPI: | 1659788339 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GONZALES | ||||||||
FirstName: | MARIA | ||||||||
MiddleName: | I | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHAVEZ | ||||||||
OtherFirstName: | MARIA | ||||||||
OtherMiddleName: | I | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 385 CALLE DE ALEGRA | ||||||||
Address2: | BLDG. A | ||||||||
City: | LAS CRUCES | ||||||||
State: | NM | ||||||||
PostalCode: | 880053423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5755261105 | ||||||||
FaxNumber: | 5755244266 | ||||||||
Practice Location | |||||||||
Address1: | 575 S ALAMEDA BLVD | ||||||||
Address2: |   | ||||||||
City: | LAS CRUCES | ||||||||
State: | NM | ||||||||
PostalCode: | 88005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5755286400 | ||||||||
FaxNumber: | 5755217199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2014 | ||||||||
LastUpdateDate: | 08/28/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M-07789 | NM | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | X-09939 | NM | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | C-09965 | NM | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 02488027 | 05 | NM |   | MEDICAID | 377434YRND | 01 | NM | MEDICARE | OTHER |