Healthcare Provider Details

I. General information

NPI: 1366594020
Provider Name (Legal Business Name): LLOYD D VIGIL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 GUSDORF ROAD BUILDING E
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 103
CHIMAYO NM
87522-0103
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-0670
  • Fax: 575-751-3557
Mailing address:
  • Phone: 505-692-3170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2168
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number267076
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: