Healthcare Provider Details

I. General information

NPI: 1992618359
Provider Name (Legal Business Name): MARYMEGAN LANGHOLTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GENN LANGHOLTZ

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4253 MONTGOMERY BLVD NE STE G130
ALBUQUERQUE NM
87109-1106
US

IV. Provider business mailing address

4273 MONTGOMERY BLVD NE STE K220
ALBUQUERQUE NM
87109-6748
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-1283
  • Fax: 505-207-6167
Mailing address:
  • Phone: 505-554-1283
  • Fax: 505-207-6167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: