MEDICARE: MS. ANGELITA JOSEPHINE MONDRAGON CAC III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	245	CO

General Provider Information

NPI Number	:	1184992240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELITA JOSEPHINE MONDRAGON CAC III

Provider Business Mailing Address
First Line	:	4055 TEJON ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80211-2214
Country	:	US
Telephone Number	:	303-953-5913
Fax Number	:	303-455-1332

Provider Business Practice Location Address
First Line	:	4055 TEJON ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80211-2214
Country	:	US
Telephone Number	:	303-953-5913
Fax Number	:	303-455-1332

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2011
Last Update Date	:	12/05/2011

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