Healthcare Provider Details

I. General information

NPI: 1689816837
Provider Name (Legal Business Name): MARLAYNA ELIZABETH RATTANAPOTE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 02/23/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 CORRALES RD SUITE 300
CORRALES NM
87048-8673
US

IV. Provider business mailing address

4231 BALBOA AVE # 130
SAN DIEGO CA
92117-5504
US

V. Phone/Fax

Practice location:
  • Phone: 858-414-3651
  • Fax:
Mailing address:
  • Phone: 858-414-3651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT - 0121911
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10634
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberT-0142131
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0147991
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: