1306804281 NPI number — MRS. CRISTINA LYNN MUGRAGE MSW

Table of content: (NPI 1801332515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306804281 NPI number — MRS. CRISTINA LYNN MUGRAGE MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUGRAGE
Provider First Name:
CRISTINA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZELLERS
Provider Other First Name:
CRISTINA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306804281
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 ORLANDO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61761-1356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-212-3606
Provider Business Mailing Address Fax Number:
888-474-1956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 N PROSPECT RD
Provider Second Line Business Practice Location Address:
SUITE A1
Provider Business Practice Location Address City Name:
PEORIA HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61616-6451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-212-3606
Provider Business Practice Location Address Fax Number:
888-474-1956
Provider Enumeration Date:
05/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149.011980 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com