Provider Demographics
NPI:1952659658
Name:ST. JAMES, CORKY (LADAC)
Entity Type:Individual
Prefix:
First Name:CORKY
Middle Name:
Last Name:ST. JAMES
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 CARLISLE BLVD. N.E.
Mailing Address - Street 2:22
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1679
Mailing Address - Country:US
Mailing Address - Phone:505-830-6030
Mailing Address - Fax:505-830-6031
Practice Address - Street 1:3150 CARLISLE BLVD NE
Practice Address - Street 2:22
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1678
Practice Address - Country:US
Practice Address - Phone:505-830-6030
Practice Address - Fax:505-830-6031
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3888101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)