Healthcare Provider Details

I. General information

NPI: 1699488163
Provider Name (Legal Business Name): VIVIAN MAGARINO-GOMEZ MA,LCMHCA, ATRP,NBCT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/29/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E CHATHAM ST STE H
APEX NC
27502-1474
US

IV. Provider business mailing address

101 E CHATHAM ST STE H.
APEX NC
27502-1474
US

V. Phone/Fax

Practice location:
  • Phone: 919-889-6928
  • Fax:
Mailing address:
  • Phone: 919-889-6928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA18373
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number21-128
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01126175
Identifier TypeOTHER
Identifier State
Identifier IssuerNATIONAL BOARD OF CERTIFIED TEACHER STANDARDS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: