Healthcare Provider Details

I. General information

NPI: 1457501538
Provider Name (Legal Business Name): MIRIAM J. CORCORAN, PH.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 TULANE DR SE
ALBUQUERQUE NM
87106-1413
US

IV. Provider business mailing address

201 TULANE DR SE
ALBUQUERQUE NM
87106-1413
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-4012
  • Fax: 505-255-4130
Mailing address:
  • Phone: 505-255-4012
  • Fax: 505-255-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number478
License Number StateNM

VIII. Authorized Official

Name: MS. MIRIIAM J CORCORAN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 505-255-4012