MEDICARE: MR. JOSEPH ANTHONY MIRABAL BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	03-234454-00-6	NM

General Provider Information

NPI Number	:	1730451055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH ANTHONY MIRABAL BA

Provider Business Mailing Address
First Line	:	8208 FEATHERTOP RD SW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87121-2090
Country	:	US
Telephone Number	:	505-350-8629
Fax Number	:

Provider Business Practice Location Address
First Line	:	8208 FEATHERTOP RD SW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87121-2090
Country	:	US
Telephone Number	:	505-350-8629
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2012
Last Update Date	:	02/01/2012

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