Provider Demographics
NPI:1316230691
Name:ENRIQUEZ, JOANNE (COTA)
Entity Type:Individual
Prefix:MS
First Name:JOANNE
Middle Name:
Last Name:ENRIQUEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 S. SANTA CRUZ ST.
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-0000
Mailing Address - Country:US
Mailing Address - Phone:515-545-3831
Mailing Address - Fax:
Practice Address - Street 1:806 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5631
Practice Address - Country:US
Practice Address - Phone:505-325-2910
Practice Address - Fax:505-325-0191
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2700224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant