Provider Demographics
NPI:1992988349
Name:GONZALES, ANTONIO MARTIN (SW)
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:MARTIN
Last Name:GONZALES
Suffix:
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 MONTEZ ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-3752
Mailing Address - Country:US
Mailing Address - Phone:505-467-3007
Mailing Address - Fax:
Practice Address - Street 1:1300 CAMINO SIERRA VIS # 125
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1007
Practice Address - Country:US
Practice Address - Phone:505-467-2504
Practice Address - Fax:505-467-2646
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-21201041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMM-2120OtherLMSW