Provider Demographics
NPI:1295859080
Name:KLIESEN-MARAVETZ, THERESA SUSAN (LPCC)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:SUSAN
Last Name:KLIESEN-MARAVETZ
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 1:813 GEORGIA ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4945
Mailing Address - Country:US
Mailing Address - Phone:505-489-1452
Mailing Address - Fax:505-232-6682
Practice Address - Street 1:813 GEORGIA ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4945
Practice Address - Country:US
Practice Address - Phone:505-489-1452
Practice Address - Fax:505-232-6682
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0101591101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health