Provider Demographics
NPI:1619557493
Name:BALDWIN, MARY JOHANA (MA, PSYD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JOHANA
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE STE 2222
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4375
Mailing Address - Country:US
Mailing Address - Phone:361-563-9307
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:361-563-9307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70930101YM0800X
NM390200000X
NMPSY-2023-0056103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program