Healthcare Provider Details

I. General information

NPI: 1649402843
Provider Name (Legal Business Name): NICOLE RIVERA-BRASTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE RIVERA-BRASTAD

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WYATT DR
LAS CRUCES NM
88005-2925
US

IV. Provider business mailing address

301 PERKINS DR STE B
LAS CRUCES NM
88005-3248
US

V. Phone/Fax

Practice location:
  • Phone: 575-526-6682
  • Fax:
Mailing address:
  • Phone: 575-526-6682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberCMF0165661
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0160171
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: