Provider Demographics
NPI:1619081734
Name:CORCORAN, MIRIAM J (PHD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:J
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM478101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN7126Medicaid
NM201002026OtherPRESBYTERIAN NUMBER
NMNM00NE75OtherBLUE CROSS NUMBER
NM850449616OtherUNITED HEALTH CARE
NM201002026OtherPRESBYTERIAN NUMBER