Provider Demographics
NPI:1043491517
Name:MUJICA, VIRGINIA RUSSELL (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:RUSSELL
Last Name:MUJICA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 PINE HILL RD
Mailing Address - Street 2:
Mailing Address - City:CASCO
Mailing Address - State:ME
Mailing Address - Zip Code:04015-4138
Mailing Address - Country:US
Mailing Address - Phone:207-650-2271
Mailing Address - Fax:
Practice Address - Street 1:41 PINE HILL RD
Practice Address - Street 2:
Practice Address - City:CASCO
Practice Address - State:ME
Practice Address - Zip Code:04015-4138
Practice Address - Country:US
Practice Address - Phone:207-650-2271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME205240000Medicaid