Healthcare Provider Details

I. General information

NPI: 1114952033
Provider Name (Legal Business Name): BRENT SCHRADER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WESTRIDGE RD
CARLSBAD NM
88220-3550
US

IV. Provider business mailing address

1900 WESTRIDGE RD
CARLSBAD NM
88220-3550
US

V. Phone/Fax

Practice location:
  • Phone: 575-725-5552
  • Fax:
Mailing address:
  • Phone: 575-725-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08687
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: