Provider Demographics
NPI:1811340060
Name:MIRABAL, KATHRYN
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:
Last Name:MIRABAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:208 JEFFERSON ST NE
Mailing Address - Street 2:APT. B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1314
Mailing Address - Country:US
Mailing Address - Phone:505-977-6986
Mailing Address - Fax:
Practice Address - Street 1:208 JEFFERSON ST NE
Practice Address - Street 2:APT. B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1314
Practice Address - Country:US
Practice Address - Phone:505-977-6986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-09559104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker