Provider Demographics
NPI:1720682479
Name:MINGO, MARIO GUY (CADC)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:GUY
Last Name:MINGO
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BAXTER DR STE 180
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-7632
Mailing Address - Country:US
Mailing Address - Phone:540-908-3917
Mailing Address - Fax:
Practice Address - Street 1:30 BAXTER DR STE 180
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-7632
Practice Address - Country:US
Practice Address - Phone:540-908-3917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710103568101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)