Provider Demographics
NPI:1922166651
Name:MCNICOL, MIGNON ELISSE (LISW)
Entity Type:Individual
Prefix:MS
First Name:MIGNON
Middle Name:ELISSE
Last Name:MCNICOL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:LELA
Other - Middle Name:MIGNON
Other - Last Name:MCNICOL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:713 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701
Mailing Address - Country:US
Mailing Address - Phone:505-429-0588
Mailing Address - Fax:505-425-6236
Practice Address - Street 1:713 6TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701
Practice Address - Country:US
Practice Address - Phone:505-429-0588
Practice Address - Fax:505-425-6236
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI21531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000F5787Medicaid