Provider Demographics
NPI:1720102874
Name:GONZALES, ANNA (LPCC)
Entity Type:Individual
Prefix:MS
First Name:ANNA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 N GONZALES ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-3452
Mailing Address - Country:US
Mailing Address - Phone:505-426-2706
Mailing Address - Fax:505-426-2782
Practice Address - Street 1:179 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3495
Practice Address - Country:US
Practice Address - Phone:505-426-2554
Practice Address - Fax:505-426-2782
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1294103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54789028Medicaid