Provider Demographics
NPI:1780048660
Name:WILKE-GARCIA, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILKE-GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2360
Mailing Address - Country:US
Mailing Address - Phone:505-342-5954
Mailing Address - Fax:
Practice Address - Street 1:707 BROADWAY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2360
Practice Address - Country:US
Practice Address - Phone:505-342-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2765101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09274260Medicaid