Provider Demographics
NPI:1073093324
Name:MONDRAGON, DESERII (LMSW)
Entity Type:Individual
Prefix:
First Name:DESERII
Middle Name:
Last Name:MONDRAGON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BULLDOG BLVD
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-1731
Mailing Address - Country:US
Mailing Address - Phone:575-746-3585
Mailing Address - Fax:
Practice Address - Street 1:405 S 6TH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-2079
Practice Address - Country:US
Practice Address - Phone:575-746-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-102451041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool