Provider Demographics
NPI:1316294911
Name:MCREYNOLDS, CORA CARISSA (MSW)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:CARISSA
Last Name:MCREYNOLDS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:CARISSA
Other - Middle Name:C
Other - Last Name:MCREYNOLDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:6409 BELLINI LN NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6400 UPTOWN BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4202
Practice Address - Country:US
Practice Address - Phone:505-670-0335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-099291041S0200X
NMX-079191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool