Healthcare Provider Details

I. General information

NPI: 1346005642
Provider Name (Legal Business Name): MARCUS BILLIE MA INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 GOLF COURSE RD SE
ALBUQUERQUE NM
87124-1999
US

IV. Provider business mailing address

636 BATAAN DR SW
ALBUQUERQUE NM
87121-2473
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-4100
  • Fax:
Mailing address:
  • Phone: 505-409-3393
  • Fax:

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: