=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558716803
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADALINE MERRY LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2016
-----------------------------------------------------
Last Update Date | 04/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 W GREENE ST
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88220-5619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-499-9435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1245
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88221-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-499-9435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 3223
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------