MEDICARE: MRS. CRISTINA LYNN MUGRAGE MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149.011980	IL

General Provider Information

NPI Number	:	1306804281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRISTINA LYNN MUGRAGE MSW

Provider Business Mailing Address
First Line	:	220 ORLANDO AVE
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-1356
Country	:	US
Telephone Number	:	309-212-3606
Fax Number	:	888-474-1956

Provider Business Practice Location Address
First Line	:	4700 N PROSPECT RD
Second Line	:	SUITE A1
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-6451
Country	:	US
Telephone Number	:	309-212-3606
Fax Number	:	888-474-1956

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	12/19/2010

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