Provider Demographics
NPI:1861629883
Name:ARCHIBEQUE, MARY M
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:ARCHIBEQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:SANCHEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1409 ELK RIDGE RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-0301
Mailing Address - Country:US
Mailing Address - Phone:505-712-6451
Mailing Address - Fax:
Practice Address - Street 1:1409 ELK RIDGE RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-0301
Practice Address - Country:US
Practice Address - Phone:505-712-6451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0168661101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12625011OtherCAQH
NM15606562Medicaid