Healthcare Provider Details

I. General information

NPI: 1023490034
Provider Name (Legal Business Name): BRENDA MEDINA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 LOS LENTES RD SE STE 3
LOS LUNAS NM
87031-6018
US

IV. Provider business mailing address

301 S CAMINO DEL PUEBLO
BERNALILLO NM
87004-6276
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-3350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10485
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: