Provider Demographics
NPI:1033235767
Name:MAYNE, BRENDA LYNN (PHD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:MAYNE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 BARBARA LOOP SE
Mailing Address - Street 2:STE. 103
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1039
Mailing Address - Country:US
Mailing Address - Phone:505-238-7081
Mailing Address - Fax:505-891-1768
Practice Address - Street 1:4011 BARBARA LOOP SE
Practice Address - Street 2:STE. 103
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1039
Practice Address - Country:US
Practice Address - Phone:505-238-7081
Practice Address - Fax:505-891-1768
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0785103T00000X
103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG2147Medicaid