Healthcare Provider Details

I. General information

NPI: 1285237461
Provider Name (Legal Business Name): BRANDON LAWRENCE MEDLEY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S CAMINO DEL PUEBLO
BERNALILLO NM
87004-6276
US

IV. Provider business mailing address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-2383
  • Fax:
Mailing address:
  • Phone: 610-620-4091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-11397
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2024-0580
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: