Provider Demographics
NPI:1720881972
Name:ALONZO, EDWARD PROCOPIO (LSAA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:PROCOPIO
Last Name:ALONZO
Suffix:
Gender:
Credentials:LSAA
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:PROCOPIO
Other - Last Name:ALONZO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSAA
Mailing Address - Street 1:2028 E AZTEC AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4804
Mailing Address - Country:US
Mailing Address - Phone:505-488-8947
Mailing Address - Fax:
Practice Address - Street 1:2028 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4804
Practice Address - Country:US
Practice Address - Phone:505-413-3447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0709101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)