Basic Information
| Provider Information | |||||||||
| NPI: | 1801106018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDDIE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 FARMINGTON AVE BLDG F | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874014559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053267878 | ||||||||
| FaxNumber: | 5053267879 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 FARMINGTON AVE BLDG F | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874014559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053267878 | ||||||||
| FaxNumber: | 5053267879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2010 | ||||||||
| LastUpdateDate: | 10/21/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0135491 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.