Provider Demographics
NPI:1467923136
Name:CORONEL, WIGBERTO MOISES (MS CLINICAL PSYCHOL)
Entity Type:Individual
Prefix:MR
First Name:WIGBERTO
Middle Name:MOISES
Last Name:CORONEL
Suffix:
Gender:M
Credentials:MS CLINICAL PSYCHOL
Other - Prefix:MR
Other - First Name:WIGBERTO
Other - Middle Name:MOISES
Other - Last Name:CORONEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1099 HANCOCK RD
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-5957
Mailing Address - Country:US
Mailing Address - Phone:928-299-3698
Mailing Address - Fax:
Practice Address - Street 1:1099 HANCOCK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-5957
Practice Address - Country:US
Practice Address - Phone:928-299-3698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2100067101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health