Healthcare Provider Details

I. General information

NPI: 1053932764
Provider Name (Legal Business Name): MS. ELISA C GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 SAN MATEO BLVD NE STE 100
ALBUQUERQUE NM
87110-3166
US

IV. Provider business mailing address

2800 SAN MATEO BLVD NE STE 100
ALBUQUERQUE NM
87110-3166
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-0146
  • Fax:
Mailing address:
  • Phone: 505-884-0146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: