Healthcare Provider Details

I. General information

NPI: 1306359369
Provider Name (Legal Business Name): ALYSSA NICOLE GONZALES LCSW, SSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA NICOLE GONZALES LMSW, QMHP

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 VERANDA RD SE
RIO RANCHO NM
87124-3897
US

IV. Provider business mailing address

1500 VERANDA RD SE
RIO RANCHO NM
87124-3897
US

V. Phone/Fax

Practice location:
  • Phone: 55-730-6522
  • Fax:
Mailing address:
  • Phone: 505-730-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-18-085
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM7536
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM-10102
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: