Provider Demographics
NPI:1447328406
Name:RAYBURN, LARRY ALAN (MA)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ALAN
Last Name:RAYBURN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 SANTA CRUZ DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3861
Mailing Address - Country:US
Mailing Address - Phone:505-988-4528
Mailing Address - Fax:
Practice Address - Street 1:1503 LLANO ST STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2000
Practice Address - Country:US
Practice Address - Phone:505-820-2921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0067152101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor