Healthcare Provider Details

I. General information

NPI: 1396383592
Provider Name (Legal Business Name): DOLORES VIGIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4185 US HIGHWAY 1 STE 102
ROCKLEDGE FL
32955-5384
US

IV. Provider business mailing address

4185 US HIGHWAY 1 STE 102
ROCKLEDGE FL
32955-5384
US

V. Phone/Fax

Practice location:
  • Phone: 321-638-0027
  • Fax:
Mailing address:
  • Phone: 321-638-0027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW10246
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: