Provider Demographics
NPI:1033646047
Name:ESPINOZA, MIQUELLA
Entity Type:Individual
Prefix:
First Name:MIQUELLA
Middle Name:
Last Name:ESPINOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:CHIMAYO
Mailing Address - State:NM
Mailing Address - Zip Code:87522-0146
Mailing Address - Country:US
Mailing Address - Phone:505-692-5200
Mailing Address - Fax:
Practice Address - Street 1:189 STATE ROAD 503 # 1A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-9780
Practice Address - Country:US
Practice Address - Phone:505-692-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician