Provider Demographics
NPI:1346909611
Name:MINGO, ALTRECIA
Entity Type:Individual
Prefix:
First Name:ALTRECIA
Middle Name:
Last Name:MINGO
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 1:9191 OAK RIDGE RD # 16
Mailing Address - Street 2:
Mailing Address - City:MER ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:71261-9691
Mailing Address - Country:US
Mailing Address - Phone:318-499-2322
Mailing Address - Fax:
Practice Address - Street 1:617 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-3833
Practice Address - Country:US
Practice Address - Phone:318-239-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16037104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty