Healthcare Provider Details

I. General information

NPI: 1447027636
Provider Name (Legal Business Name): IRMA IDALIA MIJARES LPC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2416 EASTERN PALM DR
RIO GRANDE CITY TX
78582-3467
US

IV. Provider business mailing address

2416 EASTERN PALM DR
RIO GRANDE CITY TX
78582-3467
US

V. Phone/Fax

Practice location:
  • Phone: 956-208-8846
  • Fax:
Mailing address:
  • Phone: 956-208-8846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number93563
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: