Provider Demographics
NPI:1053091124
Name:CORDOVA, ABIGAIL
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:CORDOVA
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 1:12330 PELLICANO DRIVE SUITE B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936
Mailing Address - Country:US
Mailing Address - Phone:915-613-5255
Mailing Address - Fax:
Practice Address - Street 1:12330 PELLICANO DRIVE SUITE B
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-613-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-23-284682106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician