Basic Information
| Provider Information | |||||||||
| NPI: | 1396309654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEGOLLADO | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | FRAGA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 HIGHWAY 6 STE 120 | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774784900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817692238 | ||||||||
| FaxNumber: | 2817692164 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 HIGHWAY 6 STE 120 | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774784900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817692238 | ||||||||
| FaxNumber: | 2817692164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2019 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/01/2022 | ||||||||
| NPIReactivationDate: | 08/23/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | 84723 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 373188702 | 05 | TX | MEDICAID |