Provider Demographics
NPI:1316453889
Name:CORRAL-ENRIQUEZ, STEFANIE
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:CORRAL-ENRIQUEZ
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 1:707 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2360
Mailing Address - Country:US
Mailing Address - Phone:505-345-8471
Mailing Address - Fax:505-342-5450
Practice Address - Street 1:2600 MARBLE NE BUILDING 2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-2360
Practice Address - Country:US
Practice Address - Phone:505-272-2190
Practice Address - Fax:505-272-3466
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103K00000X, 1041S0200X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool