Provider Demographics
NPI:1760470249
Name:DESOCARRAZ, MIGUEL L JR (PHD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:L
Last Name:DESOCARRAZ
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 LAKEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-6958
Mailing Address - Country:US
Mailing Address - Phone:361-779-6472
Mailing Address - Fax:361-729-1467
Practice Address - Street 1:503 LAKEWOOD ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-6958
Practice Address - Country:US
Practice Address - Phone:361-779-6472
Practice Address - Fax:361-729-1467
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21513103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033905301Medicaid
TX00HR73OtherBCBS OF TX
TX00HR73Medicare ID - Type Unspecified