Healthcare Provider Details

I. General information

NPI: 1720102874
Provider Name (Legal Business Name): ANNA GONZALES LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 BRIDGE ST
LAS VEGAS NM
87701-3495
US

IV. Provider business mailing address

2026 N GONZALES ST
LAS VEGAS NM
87701-3452
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-2554
  • Fax: 505-426-2782
Mailing address:
  • Phone: 505-426-2706
  • Fax: 505-426-2782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1294
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: