Healthcare Provider Details

I. General information

NPI: 1902335821
Provider Name (Legal Business Name): BRIAN ANTHONY LCSW, LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 JUAN TABO BLVD NE
ALBUQUERQUE NM
87112-1818
US

IV. Provider business mailing address

2424 JUAN TABO BLVD NE
ALBUQUERQUE NM
87112-1818
US

V. Phone/Fax

Practice location:
  • Phone: 505-317-3792
  • Fax:
Mailing address:
  • Phone: 505-317-3792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11377
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: