Provider Demographics
NPI:1114240280
Name:MONGIELLO, VIRGINIA KAY (MA, LPAT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:KAY
Last Name:MONGIELLO
Suffix:
Gender:F
Credentials:MA, LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1096
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-1096
Mailing Address - Country:US
Mailing Address - Phone:575-758-8892
Mailing Address - Fax:
Practice Address - Street 1:112 ALEXANDER ST
Practice Address - Street 2:SUITE B1
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6841
Practice Address - Country:US
Practice Address - Phone:575-578-8892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2923101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional