Healthcare Provider Details

I. General information

NPI: 1316686728
Provider Name (Legal Business Name): MARILYN RENEE MCKENSLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PINON & COTTIONWOOD DRIVE BUILDING 2301
SHIRPOCK NM
87420
US

IV. Provider business mailing address

PO BOX 1830
SHIPROCK NM
87420-1830
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-1050
  • Fax:
Mailing address:
  • Phone: 505-368-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2022-0116
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: