Healthcare Provider Details

I. General information

NPI: 1528049277
Provider Name (Legal Business Name): MARLA J SMITH LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE NE BLDG 2
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

2016 HACKAMORE PL SW
ALBUQUERQUE NM
87121
US

V. Phone/Fax

Practice location:
  • Phone: 505-321-0126
  • Fax:
Mailing address:
  • Phone: 505-319-3906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4183
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: