Provider Demographics
NPI:1558901330
Name:GONZALES, ANDREA (LADAC)
Entity type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7520 MONTGOMERY BLVD NE BLDG E15
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1586
Mailing Address - Country:US
Mailing Address - Phone:505-226-6380
Mailing Address - Fax:505-214-5852
Practice Address - Street 1:7520 MONTGOMERY BLVD NE BLDG E15
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1586
Practice Address - Country:US
Practice Address - Phone:505-226-6380
Practice Address - Fax:505-214-5852
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0202791101YA0400X
NMCTB-2022-0793101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)