Provider Demographics
NPI:1124187075
Name:BRAINARD, MARYTHELMA (PHD)
Entity Type:Individual
Prefix:MS
First Name:MARYTHELMA
Middle Name:
Last Name:BRAINARD
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 1:3117 10TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1114
Mailing Address - Country:US
Mailing Address - Phone:505-242-7671
Mailing Address - Fax:505-242-7671
Practice Address - Street 1:2128 SILVER AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4010
Practice Address - Country:US
Practice Address - Phone:505-242-7671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM369103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN6580Medicaid