Basic Information
| Provider Information | |||||||||
| NPI: | 1851697429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYNES | ||||||||
| FirstName: | RAYMOND | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 ADAMS ST APT G83 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052350317 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1709 MOON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871123935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052710329 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 01/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
ID Information
| ID | Type | State | Issuer | Description | 1093935959 | 05 | NM | MEDICAID |