Provider Demographics
NPI:1235666249
Name:LARRY RAYBURN PSYCHOTHERAPY
Entity Type:Organization
Organization Name:LARRY RAYBURN PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-310-5698
Mailing Address - Street 1:1411 SANTA CRUZ DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3861
Mailing Address - Country:US
Mailing Address - Phone:505-310-5698
Mailing Address - Fax:
Practice Address - Street 1:1503 LLANO ST STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2000
Practice Address - Country:US
Practice Address - Phone:505-310-5698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0100911251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health