Healthcare Provider Details

I. General information

NPI: 1710758487
Provider Name (Legal Business Name): MARCIE G. LOUDERMILK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1781 IRA DR NE
RIO RANCHO NM
87144-5444
US

IV. Provider business mailing address

1781 IRA DR NE
RIO RANCHO NM
87144-5444
US

V. Phone/Fax

Practice location:
  • Phone: 505-585-5113
  • Fax:
Mailing address:
  • Phone: 505-585-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0001
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: