Healthcare Provider Details

I. General information

NPI: 1346853082
Provider Name (Legal Business Name): VICTORIA A CARROCCIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 08/16/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 HWY 522
EL PRADO NM
87529
US

IV. Provider business mailing address

PO BOX 1511
EL PRADO NM
87529-1511
US

V. Phone/Fax

Practice location:
  • Phone: 575-613-2712
  • Fax:
Mailing address:
  • Phone: 575-613-2712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0215621
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0193781
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: