Healthcare Provider Details

I. General information

NPI: 1376076372
Provider Name (Legal Business Name): BRANDIE AJISEFINNI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 LAMBERTON PL NE
ALBUQUERQUE NM
87107-1641
US

IV. Provider business mailing address

PO BOX 21883
ALBUQUERQUE NM
87154-1883
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-8551
  • Fax:
Mailing address:
  • Phone: 510-939-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW80534
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106581
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW106581
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2023-0384
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: