Healthcare Provider Details

I. General information

NPI: 1578159851
Provider Name (Legal Business Name): BRENNAE K LEWING LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N WEST ST
SILVER CITY NM
88061-4600
US

IV. Provider business mailing address

1120 N WEST ST
SILVER CITY NM
88061-4600
US

V. Phone/Fax

Practice location:
  • Phone: 575-654-2919
  • Fax:
Mailing address:
  • Phone: 575-654-2919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCSA0214251
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: