Healthcare Provider Details

I. General information

NPI: 1083723308
Provider Name (Legal Business Name): MARY MIESEM LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PMG KASEMAN BEHAVIORAL MEDICINE 1325 WYOMING NE
ALBUQUERQUE NM
87112
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-5300
  • Fax: 505-291-5303
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number731
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: