Provider Demographics
NPI:1023186053
Name:GONZALES-ANZALDUA, EDNA ELIZABETH (LISW,LADAC)
Entity Type:Individual
Prefix:MRS
First Name:EDNA
Middle Name:ELIZABETH
Last Name:GONZALES-ANZALDUA
Suffix:
Gender:F
Credentials:LISW,LADAC
Other - Prefix:MRS
Other - First Name:EDNA
Other - Middle Name:ELIZABETH
Other - Last Name:GONZALES- ANZALDUA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW,LADAC
Mailing Address - Street 1:PO BOX 109
Mailing Address - Street 2:
Mailing Address - City:HERNANDEZ
Mailing Address - State:NM
Mailing Address - Zip Code:87537-0109
Mailing Address - Country:US
Mailing Address - Phone:505-747-7223
Mailing Address - Fax:
Practice Address - Street 1:818 S MCCURDY RD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-9646
Practice Address - Country:US
Practice Address - Phone:505-747-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-082021041C0700X
NM0118251101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)