Provider Demographics
NPI:1003009226
Name:BRUSCA, CAROL SUE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:SUE
Last Name:BRUSCA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4639 IDLEWILDE LN SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-3421
Mailing Address - Country:US
Mailing Address - Phone:505-268-5295
Mailing Address - Fax:505-268-9967
Practice Address - Street 1:5601 DOMINGO RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-268-5295
Practice Address - Fax:505-268-9967
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0097281106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB9311Medicaid