Healthcare Provider Details

I. General information

NPI: 1639444920
Provider Name (Legal Business Name): RICARDO GONZALES, PH.D., PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 AVE. PONDEROSA
GLORIETA NM
87535
US

IV. Provider business mailing address

PO BOX 325
GLORIETA NM
87535-0325
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number#414
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number#414
License Number StateNM

VIII. Authorized Official

Name: DR. RICARDO R. GONZALES
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 505-757-2216