Provider Demographics
NPI:1538131446
Name:MIGNONE, FRED RICHARD (LCSW)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:RICHARD
Last Name:MIGNONE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 GINGER LN
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-2049
Mailing Address - Country:US
Mailing Address - Phone:540-381-3101
Mailing Address - Fax:540-381-3105
Practice Address - Street 1:159 WALTERS DR
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-1041
Practice Address - Country:US
Practice Address - Phone:540-381-3101
Practice Address - Fax:540-381-3105
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040051151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008942455Medicaid
515460OtherVALUE OPTIONS
2116435OtherMAMSI
455673000OtherMAGELLAN
VA436723OtherANTHEM
7819434OtherAETNA
7819434OtherAETNA