Healthcare Provider Details

I. General information

NPI: 1174372171
Provider Name (Legal Business Name): BRANDI LEWARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 OSUNA RD NE STE H4G1
ALBUQUERQUE NM
87107-5952
US

IV. Provider business mailing address

320 OSUNA RD NE STE H4
ALBUQUERQUE NM
87107-5955
US

V. Phone/Fax

Practice location:
  • Phone: 345-277-8505
  • Fax:
Mailing address:
  • Phone: 505-345-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0325
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0576
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: