Healthcare Provider Details

I. General information

NPI: 1831101294
Provider Name (Legal Business Name): MARILYN LORRAINE GRAYSON LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 MENAUL BLVD NE SUITE 206
ALBUQUERQUE NM
87110-2871
US

IV. Provider business mailing address

3636 MENAUL BLVD NE SUITE 206
ALBUQUERQUE NM
87110-2871
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5905
  • Fax:
Mailing address:
  • Phone: 505-255-5905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number643
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: