Healthcare Provider Details

I. General information

NPI: 1760136444
Provider Name (Legal Business Name): MARY BRADTKE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3952 SAN FELIPE RD
SANTA FE NM
87507-8073
US

IV. Provider business mailing address

7 MONTANA VIS
SANTA FE NM
87507-0148
US

V. Phone/Fax

Practice location:
  • Phone: 443-569-2905
  • Fax: 505-471-8575
Mailing address:
  • Phone: 443-569-2905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0211161
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: