Provider Demographics
NPI:1730690314
Name:GONZALES, JONATHAN RYAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RYAN
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S LEAD ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-3518
Mailing Address - Country:US
Mailing Address - Phone:575-545-2685
Mailing Address - Fax:
Practice Address - Street 1:315 S LEAD ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-3518
Practice Address - Country:US
Practice Address - Phone:575-545-2685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician