Provider Demographics
NPI:1558499566
Name:GONZALES, REGINA J (LBSW)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:J
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1309
Mailing Address - Street 2:
Mailing Address - City:THOREAU
Mailing Address - State:NM
Mailing Address - Zip Code:87323-1309
Mailing Address - Country:US
Mailing Address - Phone:505-721-1819
Mailing Address - Fax:505-721-1899
Practice Address - Street 1:1000 E. AZTEC AVENUE
Practice Address - Street 2:EDUCATIONAL DEVELOPMENTAL CENTER
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-721-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-056091041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool