Provider Demographics
NPI:1639444920
Name:RICARDO GONZALES, PH.D., PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:RICARDO GONZALES, PH.D., PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:R
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-757-2216
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:GLORIETA
Mailing Address - State:NM
Mailing Address - Zip Code:87535-0325
Mailing Address - Country:US
Mailing Address - Phone:505-757-2216
Mailing Address - Fax:
Practice Address - Street 1:168 AVE. PONDEROSA
Practice Address - Street 2:
Practice Address - City:GLORIETA
Practice Address - State:NM
Practice Address - Zip Code:87535
Practice Address - Country:US
Practice Address - Phone:505-757-2216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM#414261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health