Basic Information
| Provider Information | |||||||||
| NPI: | 1053780023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRABAL | ||||||||
| FirstName: | ANNETTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 S WALNUT ST | ||||||||
| Address2: | SUITE C-6 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880012605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755275770 | ||||||||
| FaxNumber: | 5755321928 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 S WALNUT ST | ||||||||
| Address2: | SUITE C-6 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880012617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755275770 | ||||||||
| FaxNumber: | 5755321928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2015 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | C-08639 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | C-08639 | 01 | NM | NM LCSW LICENSE | OTHER |