Provider Demographics
NPI:1053819516
Name:JOHNSON, MARY LINDA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LINDA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 CHARLESTON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3605
Mailing Address - Country:US
Mailing Address - Phone:575-707-8150
Mailing Address - Fax:505-212-1446
Practice Address - Street 1:1330 SAN PEDRO DR NE STE 201B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6749
Practice Address - Country:US
Practice Address - Phone:575-707-8150
Practice Address - Fax:505-212-1446
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health