Healthcare Provider Details

I. General information

NPI: 1952297772
Provider Name (Legal Business Name): ADAM JACOB BRUE LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 SOUTHERN BLVD SE STE 105
RIO RANCHO NM
87124-5859
US

IV. Provider business mailing address

2672 CAMINO PLATA LOOP NE
RIO RANCHO NM
87144-5826
US

V. Phone/Fax

Practice location:
  • Phone: 505-270-0840
  • Fax:
Mailing address:
  • Phone: 505-364-6908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2025-0401
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: