Provider Demographics
NPI:1376900282
Name:VILLAGOMEZ, MIRELLA APOLONIA (CP60459149)
Entity Type:Individual
Prefix:
First Name:MIRELLA
Middle Name:APOLONIA
Last Name:VILLAGOMEZ
Suffix:
Gender:F
Credentials:CP60459149
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 ORCHARD ST W
Mailing Address - Street 2:BLDG. B
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98467-3824
Mailing Address - Country:US
Mailing Address - Phone:253-414-7461
Mailing Address - Fax:
Practice Address - Street 1:5915 ORCHARD ST W
Practice Address - Street 2:BLDG. B
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98467-3824
Practice Address - Country:US
Practice Address - Phone:253-414-7461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60459149101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1995208Medicaid