Basic Information
| Provider Information | |||||||||
| NPI: | 1851679260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIJANGOS | ||||||||
| FirstName: | MINERVA | ||||||||
| MiddleName: | MINNIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4705 N SONORA AVE | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937223966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592767558 | ||||||||
| FaxNumber: | 5592767568 | ||||||||
| Practice Location | |||||||||
| Address1: | 4705 N SONORA AVE | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937223966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592767558 | ||||||||
| FaxNumber: | 5592767568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2011 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 171R00000X | N | Other Service Providers | Interpreter | 101YA0400X | B5599592 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | B5599592 | 01 | CA | DRIVER'S LICENSE | OTHER |