Healthcare Provider Details

I. General information

NPI: 1538763503
Provider Name (Legal Business Name): MARK SPEIGHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CIRCULO DE VISTAS
ARROYO SECO NM
87514-0531
US

IV. Provider business mailing address

PO BOX 531
ARROYO SECO NM
87514-0531
US

V. Phone/Fax

Practice location:
  • Phone: 202-441-0546
  • Fax:
Mailing address:
  • Phone: 202-441-0546
  • Fax: 575-776-8553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0209141
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: