Provider Demographics
NPI:1306359369
Name:GONZALES, ALYSSA NICOLE (LCSW, SSW)
Entity Type:Individual
Prefix:MS
First Name:ALYSSA
Middle Name:NICOLE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LCSW, SSW
Other - Prefix:MS
Other - First Name:ALYSSA
Other - Middle Name:NICOLE
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, QMHP
Mailing Address - Street 1:1500 VERANDA RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-3897
Mailing Address - Country:US
Mailing Address - Phone:505-730-6522
Mailing Address - Fax:
Practice Address - Street 1:1500 VERANDA RD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3897
Practice Address - Country:US
Practice Address - Phone:055-730-6522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-18-085101YA0400X
ORM7536104100000X
NMM-101021041S0200X
NMSWB-2023-00151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500735164Medicaid
NM1306359369Medicaid
OR500740393Medicaid