Healthcare Provider Details

I. General information

NPI: 1912550294
Provider Name (Legal Business Name): VALARIE R GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 QUINCY ST NE
ALBUQUERQUE NM
87108-1257
US

IV. Provider business mailing address

9101 VOLCANO RD NW UNIT 58
ALBUQUERQUE NM
87121-7793
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-1306
  • Fax:
Mailing address:
  • Phone: 505-236-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: