Healthcare Provider Details

I. General information

NPI: 1932185840
Provider Name (Legal Business Name): RICARDO R GONZALES PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 AVE. DE SAN MARCOS
GLORIETA NM
87535
US

IV. Provider business mailing address

P.O BOX 375
GLORIETA NM
87535
US

V. Phone/Fax

Practice location:
  • Phone: 505-757-2216
  • Fax:
Mailing address:
  • Phone: 505-757-2216
  • Fax: 505-465-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3779
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number414
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: