Provider Demographics
NPI:1821857814
Name:VIGIL, JOSEPH GLENN (LSAA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:GLENN
Last Name:VIGIL
Suffix:
Gender:M
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12309 CONEJO RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-1517
Mailing Address - Country:US
Mailing Address - Phone:505-785-4737
Mailing Address - Fax:
Practice Address - Street 1:525 2ND ST SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3831
Practice Address - Country:US
Practice Address - Phone:505-577-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0032101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)