Provider Demographics
NPI:1720887417
Name:GONZALEZ, MARIA LOURDES (CLC)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:LOURDES
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NM
Mailing Address - Zip Code:88048-0041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 PALMILLA AVE
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NC
Practice Address - Zip Code:88048-0041
Practice Address - Country:US
Practice Address - Phone:575-496-7794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM335072174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN