Healthcare Provider Details

I. General information

NPI: 1447931183
Provider Name (Legal Business Name): SAMANTHA BRENNER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA BRENNER LMSW

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 07/26/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NM-571 BLDG 28
EL RITO NM
87530
US

IV. Provider business mailing address

PO BOX 56
ARROYO SECO NM
87514-0056
US

V. Phone/Fax

Practice location:
  • Phone: 575-581-4728
  • Fax:
Mailing address:
  • Phone: 512-876-0467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2023-0689
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: