Provider Demographics
NPI:1114952033
Name:SCHRADER, BRENT (LCSW)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:SCHRADER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WESTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3550
Mailing Address - Country:US
Mailing Address - Phone:575-725-5552
Mailing Address - Fax:
Practice Address - Street 1:1900 WESTRIDGE RD
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3550
Practice Address - Country:US
Practice Address - Phone:575-725-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-086871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84501278NMMedicaid
NM84501278Medicaid
000055266Medicare ID - Type Unspecified
Q18917Medicare UPIN
UT876000308007Medicaid