Healthcare Provider Details

I. General information

NPI: 1316288251
Provider Name (Legal Business Name): MR. MARK RICHMOND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARK GREYWOLF RICHMOND

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1532 CERRILLOS RD STE B
SANTA FE NM
87505-3512
US

IV. Provider business mailing address

1532 CERRILLOS RD STE B
SANTA FE NM
87505-3512
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-1365
  • Fax:
Mailing address:
  • Phone: 505-954-1365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number347759
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: