Provider Demographics
NPI:1124095096
Name:RAYBOULD, MARK WILLIAM (LISW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:RAYBOULD
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30811
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87190-0811
Mailing Address - Country:US
Mailing Address - Phone:505-573-4044
Mailing Address - Fax:505-573-4044
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:505-573-4044
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-049651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51681374Medicaid
NM51681374Medicaid