Healthcare Provider Details

I. General information

NPI: 1710328323
Provider Name (Legal Business Name): RAUL K GONZALEZ LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 03/23/2024
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11920 DAHLIA AVE SE
ALBUQUERQUE NM
87123-2470
US

IV. Provider business mailing address

11920 DAHLIA AVE SE
ALBUQUERQUE NM
87123-2470
US

V. Phone/Fax

Practice location:
  • Phone: 269-325-7275
  • Fax:
Mailing address:
  • Phone: 269-325-7275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0200211
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: