Provider Demographics
NPI:1932207263
Name:GONZALES, SANDRA L (SAA)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:L
Last Name:GONZALES
Suffix:
Gender:F
Credentials:SAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 N GRANT ST STE A
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-5134
Mailing Address - Country:US
Mailing Address - Phone:575-388-1447
Mailing Address - Fax:575-388-1447
Practice Address - Street 1:1311 N GRANT ST STE A
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5134
Practice Address - Country:US
Practice Address - Phone:575-388-1447
Practice Address - Fax:575-388-1447
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0124031101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid