Provider Demographics
NPI:1487205134
Name:MARQUEZ, MARK LYNN (PSR)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LYNN
Last Name:MARQUEZ
Suffix:
Gender:M
Credentials:PSR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5638
Mailing Address - Country:US
Mailing Address - Phone:505-325-0238
Mailing Address - Fax:
Practice Address - Street 1:1001 W BROADWAY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-325-0238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst