Basic Information
| Provider Information | |||||||||
| NPI: | 1598732554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONGUILLOT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | 360 BEECH STREET | ||||||||
| City: | NEWLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286570040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287335889 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 BEECH STREET | ||||||||
| Address2: | |||||||||
| City: | NEWLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286570040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287335889 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2146 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2018784 | 01 | NC | CIGNA BEHAVIORAL HEALTH | OTHER | 95177 | 01 | NC | MEDCOST | OTHER | 37263 | 01 | NC | UBH | OTHER | 0411C | 01 | NC | BCBS OF NC | OTHER | N/A | 01 | NC | CBHA | OTHER | 6000730 | 05 | NC | MEDICAID |