Healthcare Provider Details

I. General information

NPI: 1184978579
Provider Name (Legal Business Name): TARA BREMER QUINTANA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA MARIE BREMER LMSW

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11930 MENAUL BLVD NE STE 101A
ALBUQUERQUE NM
87112-2478
US

IV. Provider business mailing address

11930 MENAUL BLVD NE STE 101A
ALBUQUERQUE NM
87112-2478
US

V. Phone/Fax

Practice location:
  • Phone: 505-453-5089
  • Fax:
Mailing address:
  • Phone: 505-453-5089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-08082
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: