Healthcare Provider Details

I. General information

NPI: 1447131396
Provider Name (Legal Business Name): BRIAN ROTHROCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 UPTOWN BLVD NE
ALBUQUERQUE NM
87110-4202
US

IV. Provider business mailing address

1814 DON FELIPE RD SW
ALBUQUERQUE NM
87105-6654
US

V. Phone/Fax

Practice location:
  • Phone: 505-855-9893
  • Fax:
Mailing address:
  • Phone: 505-750-1036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSWB-2024-0322
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: