Healthcare Provider Details

I. General information

NPI: 1265797195
Provider Name (Legal Business Name): GLORIA MARIE COEQUYT M.A.,, L.P.C.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 GRANT AVE STE 309
SANTA FE NM
87501-1932
US

IV. Provider business mailing address

223 N GUADALUPE ST # 563
SANTA FE NM
87501-1868
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-5887
  • Fax:
Mailing address:
  • Phone: 505-577-5887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0636
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: