=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588843056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRENDA L WOLFE PHD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2007
-----------------------------------------------------
Last Update Date | 10/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 GRANDE SE BLVD STE B
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-1655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-884-5700
-----------------------------------------------------
Fax | 505-884-5701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 GRANDE SE BLVD STE B
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-1655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-884-5700
-----------------------------------------------------
Fax | 505-884-5701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. BRENDA L WOLFE
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 505-884-5700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0790
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------