Healthcare Provider Details

I. General information

NPI: 1730451055
Provider Name (Legal Business Name): JOSEPH ANTHONY MIRABAL BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOE A MIRABAL BA

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8208 FEATHERTOP RD SW
ALBUQUERQUE NM
87121-2090
US

IV. Provider business mailing address

8208 FEATHERTOP RD SW
ALBUQUERQUE NM
87121-2090
US

V. Phone/Fax

Practice location:
  • Phone: 505-350-8629
  • Fax:
Mailing address:
  • Phone: 505-350-8629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number03-234454-00-6
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: