Provider Demographics
NPI:1831101294
Name:GRAYSON, MARILYN LORRAINE (LPCC)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:LORRAINE
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 MENAUL BLVD NE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-2871
Mailing Address - Country:US
Mailing Address - Phone:505-255-5905
Mailing Address - Fax:
Practice Address - Street 1:3636 MENAUL BLVD NE
Practice Address - Street 2:SUITE 206
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-2871
Practice Address - Country:US
Practice Address - Phone:505-255-5905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM643101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ6156Medicaid