Provider Demographics
NPI:1831703701
Name:BURROLA, CARA JEAN
Entity type:Individual
Prefix:
First Name:CARA
Middle Name:JEAN
Last Name:BURROLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 CAPITAN ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-6909
Mailing Address - Country:US
Mailing Address - Phone:303-949-5382
Mailing Address - Fax:
Practice Address - Street 1:1111 CAPITAN ST NW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6909
Practice Address - Country:US
Practice Address - Phone:303-949-5382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO272140103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool