=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457501538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRIAM J. CORCORAN, PH.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2008
-----------------------------------------------------
Last Update Date | 09/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 TULANE DR SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-1413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-255-4012
-----------------------------------------------------
Fax | 505-255-4130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 TULANE DR SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-1413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-255-4012
-----------------------------------------------------
Fax | 505-255-4130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. MIRIIAM J CORCORAN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 505-255-4012
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 478
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------