Healthcare Provider Details

I. General information

NPI: 1255704185
Provider Name (Legal Business Name): MARY M CLINE MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 12/13/2020
Certification Date: 12/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 VISTA DE ORO
PLACITAS NM
87043-9227
US

IV. Provider business mailing address

PO BOX 93727
ALBUQUERQUE NM
87199-3727
US

V. Phone/Fax

Practice location:
  • Phone: 505-697-1717
  • Fax:
Mailing address:
  • Phone: 505-697-1717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0196071
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0196071
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: