Healthcare Provider Details

I. General information

NPI: 1841040524
Provider Name (Legal Business Name): MARIE D RAYBURN LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10203 MOUNTAIN RD NE
ALBUQUERQUE NM
87112-5236
US

IV. Provider business mailing address

10203 MOUNTAIN RD NE
ALBUQUERQUE NM
87112-5236
US

V. Phone/Fax

Practice location:
  • Phone: 505-480-7381
  • Fax:
Mailing address:
  • Phone: 505-480-7381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0098
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: