MEDICARE: ANDREA MONDRAGON

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1689320103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA MONDRAGON

Provider Business Mailing Address
First Line	:	1612 WIND RIDGE DR NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-3892
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1612 WIND RIDGE DR NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-3892
Country	:	US
Telephone Number	:	505-377-1846
Fax Number	:

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

Provider Enumeration Date	:	02/23/2022
Last Update Date	:	02/23/2022

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Directions to “ ANDREA MONDRAGON ” Practice Location

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