Healthcare Provider Details

I. General information

NPI: 1386200384
Provider Name (Legal Business Name): MRS. BRANDY L. SHINNICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS BRANDY L. WRIGHT

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH STREET
ISLETA NM
87022
US

IV. Provider business mailing address

PO BOX 640
ISLETA NM
87022-0640
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-5475
  • Fax: 505-869-4881
Mailing address:
  • Phone: 505-869-5475
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCSA0203541
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: