Provider Demographics
NPI:1255470555
Name:GONZALES, JIM L (SLP)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:L
Last Name:GONZALES
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SAN ISIDRO ST NW
Mailing Address - Street 2:COCHITI ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1038
Mailing Address - Country:US
Mailing Address - Phone:505-345-1432
Mailing Address - Fax:
Practice Address - Street 1:3100 SAN ISIDRO ST NW
Practice Address - Street 2:COCHITI ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1038
Practice Address - Country:US
Practice Address - Phone:505-345-1432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2155235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72229Medicaid