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General NPI Number Information
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NPI Number | 1063767945
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Entity Type | Organization
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Legal Business Name | AMY BRASHEAR LLC
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Dates
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Enumeration Date | 07/17/2012
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Last Update Date | 07/17/2012
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Provider Practice Location Address
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Address Line | 12805 MENAUL BLVD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87112-2547
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Country | US
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Telephone | 505-850-9419
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Fax |
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Provider Business Mailing Address
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Address Line | 12404 TULAROSA TRL NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87111-7275
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Country | US
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Telephone | 505-850-9419
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. AMY TERRELL BRASHEAR
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Credential | MC, M. DIV.
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Telephone | 505-850-9419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0095411
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License Number State | NM
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