Provider Demographics
NPI:1346853082
Name:CARROCCIO, VICTORIA A
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:CARROCCIO
Suffix:
Gender:F
Credentials:
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 1511
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-1511
Mailing Address - Country:US
Mailing Address - Phone:575-613-2712
Mailing Address - Fax:
Practice Address - Street 1:65 HWY 522
Practice Address - Street 2:
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529
Practice Address - Country:US
Practice Address - Phone:575-613-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0215621101YM0800X
NMCMH0193781101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM73725773Medicaid