Healthcare Provider Details

I. General information

NPI: 1700217601
Provider Name (Legal Business Name): MRS. TAMARA SUZANNE BIBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMARA SUZANNE MARCELAIN LPC

II. Dates (important events)

Enumeration Date: 12/03/2013
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2543 WYOMING BLVD NE
ALBUQUERQUE NM
87112-1037
US

IV. Provider business mailing address

PO BOX 2170
TIJERAS NM
87059-2170
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-3900
  • Fax: 505-294-3904
Mailing address:
  • Phone: 505-350-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0067282
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: