Provider Demographics
NPI:1346717972
Name:CORDOVA, JARELIZ ENID
Entity type:Individual
Prefix:
First Name:JARELIZ
Middle Name:ENID
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JARELIZ
Other - Middle Name:ENID
Other - Last Name:CORDOVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:80 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-4704
Mailing Address - Country:US
Mailing Address - Phone:413-665-4028
Mailing Address - Fax:
Practice Address - Street 1:80 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-4704
Practice Address - Country:US
Practice Address - Phone:413-654-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS67500351106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician