Provider Demographics
NPI:1811035751
Name:GONZALES, EUGENE
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
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 972
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025-0972
Mailing Address - Country:US
Mailing Address - Phone:928-524-2728
Mailing Address - Fax:
Practice Address - Street 1:105 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-2817
Practice Address - Country:US
Practice Address - Phone:928-524-6126
Practice Address - Fax:928-524-6090
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-1244101YA0400X
AZ256174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167332OtherAHCCCS