Provider Demographics
NPI:1164850285
Name:GONZALES, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 ROAD 6195
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417-9332
Mailing Address - Country:US
Mailing Address - Phone:505-258-4560
Mailing Address - Fax:
Practice Address - Street 1:31 ROAD 6195
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:NM
Practice Address - Zip Code:87417-9332
Practice Address - Country:US
Practice Address - Phone:505-258-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5405235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2129992021Medicaid
NM2129992021Medicaid