Provider Demographics
NPI:1952607608
Name:IRIGOYEN, MARIO HIPOLITO (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:HIPOLITO
Last Name:IRIGOYEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3572
Mailing Address - Country:US
Mailing Address - Phone:914-671-3924
Mailing Address - Fax:845-942-1894
Practice Address - Street 1:61 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3572
Practice Address - Country:US
Practice Address - Phone:914-671-3924
Practice Address - Fax:845-942-1894
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC053776001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ275406118OtherMARIO H IRIGOYEN LCSW LLC