MEDICARE: BRIAN ANTHONY LCSW, LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C-11377	NM

General Provider Information

NPI Number	:	1902335821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN ANTHONY LCSW, LICSW

Provider Business Mailing Address
First Line	:	2424 JUAN TABO BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-1818
Country	:	US
Telephone Number	:	505-317-3792
Fax Number	:

Provider Business Practice Location Address
First Line	:	2424 JUAN TABO BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-1818
Country	:	US
Telephone Number	:	505-317-3792
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	01/19/2024

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