Provider Demographics
NPI:1790810737
Name:BEMIS, MARIE CAROLYN (LPCC)
Entity Type:Individual
Prefix:
First Name:MARIE CAROLYN
Middle Name:
Last Name:BEMIS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:M. CAROLYN
Other - Middle Name:
Other - Last Name:BEMIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1606 RIDGECREST DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4437
Mailing Address - Country:US
Mailing Address - Phone:505-254-9047
Mailing Address - Fax:
Practice Address - Street 1:184 UNSER BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4045
Practice Address - Country:US
Practice Address - Phone:505-237-4098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0111941101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89620062Medicaid