Healthcare Provider Details

I. General information

NPI: 1629218631
Provider Name (Legal Business Name): CAROL ANN VIGIL LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SHEEP SPRING RD.
JEMEZ PUEBLO NM
87024
US

IV. Provider business mailing address

PO BOX 279
JEMEZ PUEBLO NM
87024-0279
US

V. Phone/Fax

Practice location:
  • Phone: 575-834-3143
  • Fax:
Mailing address:
  • Phone: 575-834-3143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0111781
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: