Provider Demographics
NPI:1538449814
Name:MAGOOSH, JOELLYN PAULINE (BA PSYCHOLOGY, LSAA)
Entity type:Individual
Prefix:MRS
First Name:JOELLYN
Middle Name:PAULINE
Last Name:MAGOOSH
Suffix:
Gender:F
Credentials:BA PSYCHOLOGY, LSAA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1301 CUBA AVE
Mailing Address - Street 2:P.O. BOX 114
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5727
Mailing Address - Country:US
Mailing Address - Phone:575-437-2453
Mailing Address - Fax:575-443-1504
Practice Address - Street 1:1301 CUBA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5727
Practice Address - Country:US
Practice Address - Phone:575-437-2453
Practice Address - Fax:575-443-1504
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0141431101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)