Provider Demographics
NPI:1730451055
Name:MIRABAL, JOSEPH ANTHONY (BA)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:MIRABAL
Suffix:
Gender:M
Credentials:BA
Other - Prefix:MR
Other - First Name:JOE
Other - Middle Name:A
Other - Last Name:MIRABAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA
Mailing Address - Street 1:8208 FEATHERTOP RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-2090
Mailing Address - Country:US
Mailing Address - Phone:505-350-8629
Mailing Address - Fax:
Practice Address - Street 1:8208 FEATHERTOP RD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-2090
Practice Address - Country:US
Practice Address - Phone:505-350-8629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM03-234454-00-6106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist