Healthcare Provider Details

I. General information

NPI: 1265511356
Provider Name (Legal Business Name): CORAL LYNN SNOWDEAL OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6519 4TH ST NW
ALBUQUERQUE NM
87107-5812
US

IV. Provider business mailing address

7623 VIA BELLEZA SW
ALBUQUERQUE NM
87121-3377
US

V. Phone/Fax

Practice location:
  • Phone: 505-342-2500
  • Fax:
Mailing address:
  • Phone: 505-400-0624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2005
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: