Healthcare Provider Details

I. General information

NPI: 1710281407
Provider Name (Legal Business Name): RICARDO FRAGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 ANCHUKA DR
SALTILLO MS
38866-5789
US

IV. Provider business mailing address

135 ANCHUKA DR
SALTILLO MS
38866-5789
US

V. Phone/Fax

Practice location:
  • Phone: 601-917-0161
  • Fax:
Mailing address:
  • Phone: 601-917-0161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1329
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: