Healthcare Provider Details

I. General information

NPI: 1699804286
Provider Name (Legal Business Name): BRAD K HOLMGREN LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CENTRAL
BAYARD NM
88023
US

IV. Provider business mailing address

226 N. CALIFORNIA AVE
SILVER CITY NM
88061
US

V. Phone/Fax

Practice location:
  • Phone: 505-537-4000
  • Fax: 505-537-3358
Mailing address:
  • Phone: 505-388-0263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI3761
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: