Healthcare Provider Details

I. General information

NPI: 1205233640
Provider Name (Legal Business Name): BRANDON JARED RENNIE ED.S., PLMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1851
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-1213
  • Fax: 505-272-3140
Mailing address:
  • Phone: 505-272-1476
  • Fax: 505-272-3140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10409
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1462
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: