Healthcare Provider Details

I. General information

NPI: 1013451897
Provider Name (Legal Business Name): BETTY LOU GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W BROADWAY STE D
FARMINGTON NM
87401-5638
US

IV. Provider business mailing address

2300 RIDGECREST DR
FARMINGTON NM
87401-3408
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4796
  • Fax:
Mailing address:
  • Phone: 505-402-6626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: