=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831101294
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN LORRAINE GRAYSON LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3636 MENAUL BLVD NE SUITE 206
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-2871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-255-5905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3636 MENAUL BLVD NE SUITE 206
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-2871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-255-5905
-----------------------------------------------------
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 | 643
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------