MEDICARE: IGNACIO BIDEGAIN LCMHCA NCC

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	101YM0800X	Mental Health Counselor	A17794	NC

General Provider Information

NPI Number	:	1356110944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IGNACIO BIDEGAIN LCMHCA NCC

Provider Business Mailing Address
First Line	:	3403 TIMBER MILL DR
Second Line	:
City	:	STALLINGS
State	:	NC
Zip	:	28104-1156
Country	:	US
Telephone Number	:	404-667-4236
Fax Number	:

Provider Business Practice Location Address
First Line	:	3403 TIMBER MILL DR
Second Line	:
City	:	STALLINGS
State	:	NC
Zip	:	28104-1156
Country	:	US
Telephone Number	:	404-667-4236
Fax Number	:

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

Provider Enumeration Date	:	12/25/2023
Last Update Date	:	02/07/2024

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