Healthcare Provider Details

I. General information

NPI: 1477544641
Provider Name (Legal Business Name): MARY E. ALONZO I
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 ESTANCIA DR NW
ALBUQUERQUE NM
87105-1867
US

IV. Provider business mailing address

240 ESTANCIA DR NW
ALBUQUERQUE NM
87105-1867
US

V. Phone/Fax

Practice location:
  • Phone: 505-836-5201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1458
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: