Healthcare Provider Details

I. General information

NPI: 1205207834
Provider Name (Legal Business Name): MARY THAYER-REGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 CONSTITUTION AVE NE SUITE 4
ALBUQUERQUE NM
87110-5900
US

IV. Provider business mailing address

6020 CONSTITUTION AVE NE SUITE 4
ALBUQUERQUE NM
87110-5900
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-5099
  • Fax: 505-255-4206
Mailing address:
  • Phone: 505-255-5099
  • Fax: 505-255-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3149
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: