Provider Demographics
NPI:1598837841
Name:AGOLIA, MARY ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY ELLEN
Middle Name:
Last Name:AGOLIA
Suffix:
Gender:F
Credentials:PHD
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 351
Mailing Address - Street 2:
Mailing Address - City:HIGH ROLLS MOUNTAIN PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88325-0351
Mailing Address - Country:US
Mailing Address - Phone:575-430-4115
Mailing Address - Fax:866-561-1508
Practice Address - Street 1:20 COTTAGE ROW
Practice Address - Street 2:UNIT B
Practice Address - City:HIGH ROLLS MOUNTAIN PARK
Practice Address - State:NM
Practice Address - Zip Code:88325-9010
Practice Address - Country:US
Practice Address - Phone:575-430-4115
Practice Address - Fax:866-561-1508
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1188101YM0800X
NMM0432104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN3745Medicaid