Provider Demographics
NPI:1891063194
Name:CORRAL, JOSE DANIEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:DANIEL
Last Name:CORRAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6415 WINDING RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-7555
Mailing Address - Country:US
Mailing Address - Phone:702-354-7138
Mailing Address - Fax:
Practice Address - Street 1:3435 W CRAIG RD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5115
Practice Address - Country:US
Practice Address - Phone:702-750-0377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst