Provider Demographics
NPI:1407268147
Name:ANDRADE, MARYJO ELLEN (LMHC)
Entity Type:Individual
Prefix:
First Name:MARYJO
Middle Name:ELLEN
Last Name:ANDRADE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10019 KING RANCH LN SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-5311
Mailing Address - Country:US
Mailing Address - Phone:505-331-6404
Mailing Address - Fax:
Practice Address - Street 1:10019 KING RANCH LN SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-5311
Practice Address - Country:US
Practice Address - Phone:505-503-1047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0165641101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health