Healthcare Provider Details

I. General information

NPI: 1619351988
Provider Name (Legal Business Name): KACEY GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE BLDG A
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

933 BRADBURY DR SE
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2024-0222
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: