Healthcare Provider Details

I. General information

NPI: 1861629883
Provider Name (Legal Business Name): MARY M ARCHIBEQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY M SANCHEZ

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 ELK RIDGE RD NE
ALBUQUERQUE NM
87113-0301
US

IV. Provider business mailing address

1409 ELK RIDGE RD NE
ALBUQUERQUE NM
87113-0301
US

V. Phone/Fax

Practice location:
  • Phone: 505-712-6451
  • Fax:
Mailing address:
  • Phone: 505-712-6451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0168661
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: