Healthcare Provider Details

I. General information

NPI: 1770958852
Provider Name (Legal Business Name): BRENDA LEOS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E MESCALERO RD
ROSWELL NM
88201-6542
US

IV. Provider business mailing address

1515 W FIR ST
PORTALES NM
88130-5703
US

V. Phone/Fax

Practice location:
  • Phone: 575-755-2272
  • Fax: 575-622-3325
Mailing address:
  • Phone: 575-356-6695
  • Fax: 575-356-5948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0176671
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: