Healthcare Provider Details

I. General information

NPI: 1710102090
Provider Name (Legal Business Name): GREGORY LEE GONZALES M.S., LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 MONTANA AVE STE E
LAS CRUCES NM
88001-4294
US

IV. Provider business mailing address

650 MONTANA AVE STE E
LAS CRUCES NM
88001-4294
US

V. Phone/Fax

Practice location:
  • Phone: 575-202-7047
  • Fax: 575-647-8050
Mailing address:
  • Phone: 575-202-7047
  • Fax: 575-647-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number006090
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: