Provider Demographics
NPI:1447531793
Name:NAGORSKI, MARIA JENNIFER VICUNA
Entity type:Individual
Prefix:
First Name:MARIA JENNIFER
Middle Name:VICUNA
Last Name:NAGORSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 ACADEMY RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1107
Mailing Address - Country:US
Mailing Address - Phone:505-821-3628
Mailing Address - Fax:505-856-7103
Practice Address - Street 1:8600 ACADEMY RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1107
Practice Address - Country:US
Practice Address - Phone:505-821-3628
Practice Address - Fax:505-856-7103
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0141951101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health