Healthcare Provider Details

I. General information

NPI: 1003641184
Provider Name (Legal Business Name): MARISSA SIECK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CARLISLE BLVD NE STE 105229
ALBUQUERQUE NM
87110-1678
US

IV. Provider business mailing address

3908 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4504
US

V. Phone/Fax

Practice location:
  • Phone: 505-633-8173
  • Fax:
Mailing address:
  • Phone: 505-639-5916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2026-0756
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: