Provider Demographics
NPI:1932185840
Name:GONZALES, RICARDO R (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:R
Last Name:GONZALES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 375
Mailing Address - Street 2:
Mailing Address - City:GLORIETA
Mailing Address - State:NM
Mailing Address - Zip Code:87535
Mailing Address - Country:US
Mailing Address - Phone:505-757-2216
Mailing Address - Fax:505-465-1155
Practice Address - Street 1:168 AVE. DE SAN MARCOS
Practice Address - Street 2:
Practice Address - City:GLORIETA
Practice Address - State:NM
Practice Address - Zip Code:87535
Practice Address - Country:US
Practice Address - Phone:505-757-2216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3779101YA0400X
NM414103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN1903Medicaid
NMN6708/N1903Medicaid
NMN6708Medicaid
NMN1903Medicaid
NM8HBF04Medicare PIN
NM8HBD89Medicare PIN
NM8HBD88Medicare PIN
NM8HBD87Medicare PIN