Provider Demographics
NPI:1225262876
Name:GONZALES, SHARON ANTONIA (CCSW)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:ANTONIA
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 LUTHY DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2849
Mailing Address - Country:US
Mailing Address - Phone:505-804-8094
Mailing Address - Fax:
Practice Address - Street 1:1828 LUTHY NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112
Practice Address - Country:US
Practice Address - Phone:505-804-8094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM$$$$$$$$$Medicaid