Healthcare Provider Details

I. General information

NPI: 1184454530
Provider Name (Legal Business Name): MARYANNE ESABELLA MICELI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13139 CENTRAL AVE NE
ALBUQUERQUE NM
87123-3031
US

IV. Provider business mailing address

13139 CENTRAL AVE NE
ALBUQUERQUE NM
87123-3031
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-5054
  • Fax:
Mailing address:
  • Phone: 505-459-5054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1184454530
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: