Provider Demographics
NPI:1306503339
Name:MONDRAGON, CYNTHIA A (BS, SLP-A)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:MONDRAGON
Suffix:
Gender:F
Credentials:BS, SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 594
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NM
Mailing Address - Zip Code:88230-0594
Mailing Address - Country:US
Mailing Address - Phone:575-317-1163
Mailing Address - Fax:
Practice Address - Street 1:400 1ST ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:NM
Practice Address - Zip Code:88230
Practice Address - Country:US
Practice Address - Phone:575-734-5434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLPA75502355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant