Healthcare Provider Details

I. General information

NPI: 1861742926
Provider Name (Legal Business Name): MARYAH JEAN VIGIL LPCC; CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 BROADWAY BLVD SE
ALBUQUERQUE NM
87102-3425
US

IV. Provider business mailing address

218 BROADWAY BLVD SE
ALBUQUERQUE NM
87102-3425
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-6988
  • Fax: 505-242-6972
Mailing address:
  • Phone: 505-242-6988
  • Fax: 505-242-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0175211
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: