Provider Demographics
NPI:1649704776
Name:MARY M CLINE, LLC
Entity type:Organization
Organization Name:MARY M CLINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, AUTHORIZED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPCC
Authorized Official - Phone:505-697-1717
Mailing Address - Street 1:33 VISTA DE ORO
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-9227
Mailing Address - Country:US
Mailing Address - Phone:505-697-1717
Mailing Address - Fax:
Practice Address - Street 1:33 VISTA DE ORO
Practice Address - Street 2:
Practice Address - City:PLACITAS
Practice Address - State:NM
Practice Address - Zip Code:87043-9227
Practice Address - Country:US
Practice Address - Phone:505-697-1717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-15
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17507898Medicaid