Healthcare Provider Details

I. General information

NPI: 1053819516
Provider Name (Legal Business Name): MARY LINDA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 SAN PEDRO DR NE STE 201B
ALBUQUERQUE NM
87110-6749
US

IV. Provider business mailing address

2617 CHARLESTON ST NE
ALBUQUERQUE NM
87110-3605
US

V. Phone/Fax

Practice location:
  • Phone: 575-707-8150
  • Fax: 505-212-1446
Mailing address:
  • Phone: 575-707-8150
  • Fax: 505-212-1446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: