Healthcare Provider Details

I. General information

NPI: 1811162241
Provider Name (Legal Business Name): ALAN BRODY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2008
Last Update Date: 04/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 DON GASPAR AVE
SANTA FE NM
87505-2626
US

IV. Provider business mailing address

532 DON GASPAR AVE
SANTA FE NM
87505-2626
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-3478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI1310
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: