Provider Demographics
NPI:1922791557
Name:GONZALES, ALISA (CCSS)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CCSS
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 456
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-0456
Mailing Address - Country:US
Mailing Address - Phone:575-835-4357
Mailing Address - Fax:505-514-0732
Practice Address - Street 1:614 BECKER AVE
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3634
Practice Address - Country:US
Practice Address - Phone:575-835-4357
Practice Address - Fax:505-514-0732
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator