MEDICARE: BROWNDOG COUNSELING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1265174726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROWNDOG COUNSELING, LLC

Provider Business Mailing Address
First Line	:	3708 BRYN MAWR DR NE APT C
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-4361
Country	:	US
Telephone Number	:	505-394-8037
Fax Number	:

Provider Business Practice Location Address
First Line	:	3708 BRYN MAWR DR NE APT C
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-4361
Country	:	US
Telephone Number	:	505-394-8037
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	TRAVIS SCOTT
Credential	:	MSSA, LISW-S, LCSW
Telephone Number	:	505-394-8037

Provider Enumeration Date	:	04/13/2022
Last Update Date	:	04/13/2022

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