Healthcare Provider Details

I. General information

NPI: 1134239700
Provider Name (Legal Business Name): CAROL A. BRENNAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4686 CORRALES RD #4E
CORRALES NM
87048-8610
US

IV. Provider business mailing address

4686 CORRALES RD #4E
CORRALES NM
87048-8610
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-7077
  • Fax: 505-890-1313
Mailing address:
  • Phone: 505-255-7077
  • Fax: 505-890-1313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0519
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: