Provider Demographics
NPI:1720486772
Name:PERFECTLY IMPERFECT
Entity Type:Organization
Organization Name:PERFECTLY IMPERFECT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:CAGLIOSTRO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LADAC
Authorized Official - Phone:505-550-1306
Mailing Address - Street 1:4720 PERSHING AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-3438
Mailing Address - Country:US
Mailing Address - Phone:505-220-5481
Mailing Address - Fax:
Practice Address - Street 1:146 QUINCY ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-550-1306
Practice Address - Fax:844-434-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34155384Medicaid