Provider Demographics
NPI:1851679260
Name:MIJANGOS, MINERVA MINNIE (AA)
Entity Type:Individual
Prefix:MS
First Name:MINERVA
Middle Name:MINNIE
Last Name:MIJANGOS
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 N SONORA AVE
Mailing Address - Street 2:SUITE 113
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-3966
Mailing Address - Country:US
Mailing Address - Phone:559-276-7558
Mailing Address - Fax:559-276-7568
Practice Address - Street 1:4705 N SONORA AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-3966
Practice Address - Country:US
Practice Address - Phone:559-276-7558
Practice Address - Fax:559-276-7568
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 171R00000X
CAB5599592101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171R00000XOther Service ProvidersInterpreter
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB5599592OtherDRIVER'S LICENSE