Healthcare Provider Details

I. General information

NPI: 1184166423
Provider Name (Legal Business Name): MARCIE ANN BURNS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 WILSHIRE AVE NE STE C
ALBUQUERQUE NM
87113-2569
US

IV. Provider business mailing address

5501 WILSHIRE AVE NE STE C
ALBUQUERQUE NM
87113-2569
US

V. Phone/Fax

Practice location:
  • Phone: 505-399-9135
  • Fax:
Mailing address:
  • Phone: 505-399-9135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM09612
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10814
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: