Provider Demographics
NPI:1013421619
Name:MJ ZIMMERMAN LPCC, LLC
Entity Type:Organization
Organization Name:MJ ZIMMERMAN LPCC, LLC
Other - Org Name:MJ ZIMMERMAN LPCC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-573-2339
Mailing Address - Street 1:4808 TEODOCIO ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3359
Mailing Address - Country:US
Mailing Address - Phone:505-573-2339
Mailing Address - Fax:
Practice Address - Street 1:4916 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-3949
Practice Address - Country:US
Practice Address - Phone:505-573-2339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0188201251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15883086Medicaid