Provider Demographics
NPI:1659672632
Name:VIGIL, MOSES EDWARD (LCSW)
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:EDWARD
Last Name:VIGIL
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 1:2912 40TH LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81022-9810
Mailing Address - Country:US
Mailing Address - Phone:719-671-7570
Mailing Address - Fax:719-543-8352
Practice Address - Street 1:208 W 8TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3023
Practice Address - Country:US
Practice Address - Phone:719-671-7570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9917121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical