Healthcare Provider Details

I. General information

NPI: 1497568257
Provider Name (Legal Business Name): MARKUS MACEO SR. INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3949 CORRALES RD STE 205
CORRALES NM
87048-9348
US

IV. Provider business mailing address

3949 CORRALES RD STE 205
CORRALES NM
87048-9348
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-0439
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: