Provider Demographics
NPI:1962825018
Name:GONZALES, YVETTE (LBSW)
Entity Type:Individual
Prefix:
First Name:YVETTE
Middle Name:
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 1:900 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88023
Mailing Address - Country:US
Mailing Address - Phone:575-537-4000
Mailing Address - Fax:575-537-3921
Practice Address - Street 1:900 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023
Practice Address - Country:US
Practice Address - Phone:575-537-4000
Practice Address - Fax:575-537-3921
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-39731041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000L1871Medicaid