Healthcare Provider Details

I. General information

NPI: 1336120625
Provider Name (Legal Business Name): MARLENE ELAINE PHILLIPS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE NE
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

6211 SUNRAY RD NW
ALBUQUERQUE NM
87120-6141
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5109
  • Fax:
Mailing address:
  • Phone: 505-836-1142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0076031
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: