Healthcare Provider Details

I. General information

NPI: 1952705428
Provider Name (Legal Business Name): MELISSA MAYBERRY DEWLEN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA KAREN MAYBERRY

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6612 GULTON CT NE STE A
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

8644 MOCK HEATHER RD NW
ALBUQUERQUE NM
87120-4250
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-1686
  • Fax: 505-888-1683
Mailing address:
  • Phone: 972-989-0344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0198061
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: