Provider Demographics
NPI:1144451766
Name:GONZALEZ, GUSTAVO (LISW)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 GUSDORF RD STE M
Mailing Address - Street 2:PO BOX 2238
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-7200
Mailing Address - Country:US
Mailing Address - Phone:575-758-4297
Mailing Address - Fax:575-751-7237
Practice Address - Street 1:1337 GUSDORF ROAD, SUITE M
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6671
Practice Address - Country:US
Practice Address - Phone:575-758-4297
Practice Address - Fax:575-751-7237
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 34411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT 8238Medicaid