Provider Demographics
NPI:1700217601
Name:BIBO, TAMARA SUZANNE
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:SUZANNE
Last Name:BIBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:SUZANNE
Other - Last Name:MARCELAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 2170
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-2170
Mailing Address - Country:US
Mailing Address - Phone:505-350-1321
Mailing Address - Fax:
Practice Address - Street 1:2543 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1037
Practice Address - Country:US
Practice Address - Phone:505-294-3900
Practice Address - Fax:505-294-3904
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0067282101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health