Provider Demographics
NPI:1306804281
Name:MUGRAGE, CRISTINA LYNN (MSW)
Entity type:Individual
Prefix:MRS
First Name:CRISTINA
Middle Name:LYNN
Last Name:MUGRAGE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:CRISTINA
Other - Middle Name:LYNN
Other - Last Name:ZELLERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:220 ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1356
Mailing Address - Country:US
Mailing Address - Phone:309-212-3606
Mailing Address - Fax:888-474-1956
Practice Address - Street 1:4700 N PROSPECT RD
Practice Address - Street 2:SUITE A1
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-6451
Practice Address - Country:US
Practice Address - Phone:309-212-3606
Practice Address - Fax:888-474-1956
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2010-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0119801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical