Provider Demographics
NPI:1457501538
Name:MIRIAM J. CORCORAN, PH.D., INC.
Entity Type:Organization
Organization Name:MIRIAM J. CORCORAN, PH.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MIRIIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-255-4012
Mailing Address - Street 1:201 TULANE DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1413
Mailing Address - Country:US
Mailing Address - Phone:505-255-4012
Mailing Address - Fax:505-255-4130
Practice Address - Street 1:201 TULANE DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1413
Practice Address - Country:US
Practice Address - Phone:505-255-4012
Practice Address - Fax:505-255-4130
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIRIAM J. CORCORAN, PH.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM478103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00NE75OtherBLUE CROSS OF NM