Healthcare Provider Details

I. General information

NPI: 1386761666
Provider Name (Legal Business Name): MARIE M LEYBA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 CALLE DON DIEGO
ESPANOLA NM
87532-3414
US

IV. Provider business mailing address

PO BOX 464
VELARDE NM
87582-0464
US

V. Phone/Fax

Practice location:
  • Phone: 505-362-3342
  • Fax:
Mailing address:
  • Phone: 505-927-1092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM-04665
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: