Provider Demographics
NPI:1144795956
Name:HENDRICKS, BRENNA
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 RIDGECREST DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5152
Mailing Address - Country:US
Mailing Address - Phone:505-610-4305
Mailing Address - Fax:
Practice Address - Street 1:500 UNSER BLVD SE STE 103
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4660
Practice Address - Country:US
Practice Address - Phone:505-916-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMH0195401101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health