Healthcare Provider Details

I. General information

NPI: 1679314017
Provider Name (Legal Business Name): MALLORY RAE MICHELE PATTERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 JEFFERSON ST NE STE 301
ALBUQUERQUE NM
87109-7390
US

IV. Provider business mailing address

4075A MERCURY CIR SE
ALBUQUERQUE NM
87116-3020
US

V. Phone/Fax

Practice location:
  • Phone: 505-705-1701
  • Fax: 505-212-1253
Mailing address:
  • Phone: 228-243-5727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: