1639444920 NPI number — RICARDO GONZALES, PH.D., PSYCHOLOGICAL SERVICES, LLC

Table of content: (NPI 1639444920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639444920 NPI number — RICARDO GONZALES, PH.D., PSYCHOLOGICAL SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICARDO GONZALES, PH.D., PSYCHOLOGICAL SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639444920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 325
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLORIETA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87535-0325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-757-2216
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
168 AVE. PONDEROSA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLORIETA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-757-2216
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALES
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
505-757-2216

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  #414 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0855X , with the licence number: #414 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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