Healthcare Provider Details

I. General information

NPI: 1649704776
Provider Name (Legal Business Name): MARY M CLINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2017
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 VISTA DE ORO
PLACITAS NM
87043-9227
US

IV. Provider business mailing address

33 VISTA DE ORO
PLACITAS NM
87043-9227
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 Number
License Number State

VIII. Authorized Official

Name: MS. MARY M CLINE
Title or Position: OWNER, AUTHORIZED AGENT
Credential: MA, LPCC
Phone: 505-697-1717