Healthcare Provider Details

I. General information

NPI: 1720881972
Provider Name (Legal Business Name): EDWARD PROCOPIO ALONZO LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: EDWARD PROCOPIO ALONZO LSAA

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2028 E AZTEC AVE
GALLUP NM
87301-4804
US

IV. Provider business mailing address

2028 E AZTEC AVE
GALLUP NM
87301-4804
US

V. Phone/Fax

Practice location:
  • Phone: 505-413-3447
  • Fax:
Mailing address:
  • Phone: 505-488-8947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2022-0709
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: