Healthcare Provider Details

I. General information

NPI: 1821451527
Provider Name (Legal Business Name): RACHEL MONDRAGON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SWOPE PARK AVE NE
ALBUQUERQUE NM
87123-5431
US

IV. Provider business mailing address

500 SWOPE PARK AVE NE
ALBUQUERQUE NM
87123-5431
US

V. Phone/Fax

Practice location:
  • Phone: 505-263-0023
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-08069
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: