Provider Demographics
NPI:1770762775
Name:MARK W RAYBOULD, LISW, INC
Entity type:Organization
Organization Name:MARK W RAYBOULD, LISW, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SOLE OWNER PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:RAYBOULD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-573-4044
Mailing Address - Street 1:2811 INDIAN SCHOOL RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1825
Mailing Address - Country:US
Mailing Address - Phone:505-573-4044
Mailing Address - Fax:505-212-0975
Practice Address - Street 1:2811 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1825
Practice Address - Country:US
Practice Address - Phone:505-573-4044
Practice Address - Fax:505-212-0975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM01JC33OtherBLUE CROSS
NM81951876Medicaid
NM10020766OtherLOVELACE HEALTH PLAN
NM10020766OtherLOVELACE HEALTH PLAN