MEDICARE: MARIE D RAYBURN LSAA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CTB-2024-0098	NM

General Provider Information

NPI Number	:	1841040524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE D RAYBURN LSAA

Provider Business Mailing Address
First Line	:	10203 MOUNTAIN RD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-5236
Country	:	US
Telephone Number	:	505-480-7381
Fax Number	:

Provider Business Practice Location Address
First Line	:	10203 MOUNTAIN RD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-5236
Country	:	US
Telephone Number	:	505-480-7381
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2024
Last Update Date	:	04/08/2026

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