Healthcare Provider Details

I. General information

NPI: 1720103823
Provider Name (Legal Business Name): JOELLE LIZETTE BRACKEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LASER RD NE
RIO RANCHO NM
87124-4517
US

IV. Provider business mailing address

1425 MONTIANO LOOP SE
RIO RANCHO NM
87124-8769
US

V. Phone/Fax

Practice location:
  • Phone: 505-627-2562
  • Fax:
Mailing address:
  • Phone: 575-910-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number256905
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0806
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: