Provider Demographics
NPI:1780666511
Name:MUNGUIA WELLMAN, MARIA GLORIA (LISW)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:GLORIA
Last Name:MUNGUIA WELLMAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:202 BRYN MAWR DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2103
Mailing Address - Country:US
Mailing Address - Phone:505-272-2190
Mailing Address - Fax:505-272-3466
Practice Address - Street 1:2600 MARBLE NE, BUILDING 2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-2190
Practice Address - Fax:505-272-3466
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-047181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA2696Medicaid