Provider Demographics
NPI:1467767038
Name:MANDAGARAN, YVONNE M (LPPC)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:M
Last Name:MANDAGARAN
Suffix:
Gender:F
Credentials:LPPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 62 BOX 2909
Mailing Address - Street 2:
Mailing Address - City:THOREAU
Mailing Address - State:NM
Mailing Address - Zip Code:87323-9505
Mailing Address - Country:US
Mailing Address - Phone:505-240-1290
Mailing Address - Fax:
Practice Address - Street 1:HC 62 BOX 2909
Practice Address - Street 2:
Practice Address - City:THOREAU
Practice Address - State:NM
Practice Address - Zip Code:87323-9505
Practice Address - Country:US
Practice Address - Phone:505-240-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-08
Last Update Date:2010-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0126051101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM435Medicaid