Healthcare Provider Details

I. General information

NPI: 1457710352
Provider Name (Legal Business Name): MARINELL LOCSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 PENNSYLVANIA ST NE SUITE E
ALBUQUERQUE NM
87110-3613
US

IV. Provider business mailing address

1704 PRINCETON DR SE
ALBUQUERQUE NM
87106-3114
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4400
  • Fax:
Mailing address:
  • Phone: 505-363-5636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT0178921
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: