Provider Demographics
NPI:1407532849
Name:MONDRAGON, HOLLY M
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:M
Last Name:MONDRAGON
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 94
Mailing Address - Street 2:
Mailing Address - City:ALCALDE
Mailing Address - State:NM
Mailing Address - Zip Code:87511-0094
Mailing Address - Country:US
Mailing Address - Phone:505-927-9885
Mailing Address - Fax:
Practice Address - Street 1:502 W CORDOVA RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1820
Practice Address - Country:US
Practice Address - Phone:877-426-8095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLPCF23019235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist