Provider Demographics
NPI:1053780023
Name:MIRABAL, ANNETTE
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:MIRABAL
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 1:151 S WALNUT ST
Mailing Address - Street 2:SUITE C-6
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-2605
Mailing Address - Country:US
Mailing Address - Phone:575-527-5770
Mailing Address - Fax:575-532-1928
Practice Address - Street 1:151 S WALNUT ST
Practice Address - Street 2:SUITE C-6
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-2617
Practice Address - Country:US
Practice Address - Phone:575-527-5770
Practice Address - Fax:575-532-1928
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-08639104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMC-08639OtherNM LCSW LICENSE