Healthcare Provider Details

I. General information

NPI: 1790195998
Provider Name (Legal Business Name): BROOKE ALISSA CHAPLA PSY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BROOKE ALISSA WALLS

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INTERNAL MEDICINE 401 SAN MATEO BLVD SE
ALBUQUERQUE NM
87108-2921
US

IV. Provider business mailing address

INTERNAL MEDICINE 401 SAN MATEO BLVD SE
ALBUQUERQUE NM
87108-2921
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-7333
  • Fax: 505-462-7440
Mailing address:
  • Phone: 505-462-7333
  • Fax: 505-462-7440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number10098
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1635
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: