Healthcare Provider Details

I. General information

NPI: 1114240280
Provider Name (Legal Business Name): VIRGINIA KAY MONGIELLO MA, LPAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 ALEXANDER ST SUITE B1
TAOS NM
87571-6841
US

IV. Provider business mailing address

PO BOX 1096
EL PRADO NM
87529-1096
US

V. Phone/Fax

Practice location:
  • Phone: 575-578-8892
  • Fax:
Mailing address:
  • Phone: 575-758-8892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2923
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: