Healthcare Provider Details

I. General information

NPI: 1558499566
Provider Name (Legal Business Name): REGINA J GONZALES LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E. AZTEC AVENUE EDUCATIONAL DEVELOPMENTAL CENTER
GALLUP NM
87301
US

IV. Provider business mailing address

PO BOX 1309
THOREAU NM
87323-1309
US

V. Phone/Fax

Practice location:
  • Phone: 505-721-1819
  • Fax:
Mailing address:
  • Phone: 505-721-1819
  • Fax: 505-721-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberB-05609
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: