Provider Demographics
NPI:1134662067
Name:BROOKS, MARIAH RAINE
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:RAINE
Last Name:BROOKS
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 1:821 COUNTRY CLUB DR SE
Mailing Address - Street 2:#1C
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2297
Mailing Address - Country:US
Mailing Address - Phone:505-269-0861
Mailing Address - Fax:
Practice Address - Street 1:821 COUNTRY CLUB DR SE
Practice Address - Street 2:#1C
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-2297
Practice Address - Country:US
Practice Address - Phone:505-269-0861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-25
Last Update Date:2016-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician