1518074749 NPI number — BRENDA RAE ABERCROMBIE MA, LPCC, LADAC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518074749 NPI number — BRENDA RAE ABERCROMBIE MA, LPCC, LADAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABERCROMBIE
Provider First Name:
BRENDA
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPCC, LADAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ATWOOD
Provider Other First Name:
BRENDA
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518074749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMOGORDO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88311-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-585-4319
Provider Business Mailing Address Fax Number:
575-993-5303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 ST FRANCIS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULAROSA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88352-2328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-585-4319
Provider Business Practice Location Address Fax Number:
575-993-5303
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  1271 (LPCC) , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: 006083 (LADAC) , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NM01JA60 . This is a "BCBS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM101063 . This is a "VALUEOPTIONS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 24078 . This is a "LOVELACE HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 97235211 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201023019 . This is a "PRESBYTERIAN HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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