Provider Demographics
NPI:1538443452
Name:CORRAL, MACARENA MAYERLE (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:MACARENA
Middle Name:MAYERLE
Last Name:CORRAL
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6425 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1675
Mailing Address - Country:US
Mailing Address - Phone:612-798-8168
Mailing Address - Fax:
Practice Address - Street 1:6425 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1675
Practice Address - Country:US
Practice Address - Phone:612-798-8168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5396103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TF0200X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1750552196OtherBCBS
MN87055600Medicaid
MNC01290OtherMEDICARE PTAN