Provider Demographics
NPI:1275832511
Name:ZIMMERMAN, MARY JANE (LPCC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4808 TEODOCIO ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3359
Mailing Address - Country:US
Mailing Address - Phone:505-573-2339
Mailing Address - Fax:
Practice Address - Street 1:6501 4TH ST NW STE E-2
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107
Practice Address - Country:US
Practice Address - Phone:505-226-4624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0188201101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health