Healthcare Provider Details

I. General information

NPI: 1679020366
Provider Name (Legal Business Name): BRENNA ANN DOTSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-7764
  • Fax: 505-272-3742
Mailing address:
  • Phone: 505-925-7764
  • Fax: 505-272-3742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-3199
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: