Healthcare Provider Details

I. General information

NPI: 1922529619
Provider Name (Legal Business Name): MARY PAMELA COLTON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2218 SOUTHERN BLVD SE STE 14
RIO RANCHO NM
87124-3750
US

IV. Provider business mailing address

PO BOX 664
PLACITAS NM
87043-0664
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-0161
  • Fax: 505-994-0162
Mailing address:
  • Phone: 505-550-7129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1489
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: