Provider Demographics
NPI:1598168684
Name:MUNGUIA, VIRIDIANA
Entity Type:Individual
Prefix:
First Name:VIRIDIANA
Middle Name:
Last Name:MUNGUIA
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 1:500 N 9TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5814
Mailing Address - Country:US
Mailing Address - Phone:209-341-1824
Mailing Address - Fax:
Practice Address - Street 1:500 N 9TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5814
Practice Address - Country:US
Practice Address - Phone:209-341-1824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW72108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942609766OtherINTERN MED-CAL BILLING