Provider Demographics
NPI:1164670709
Name:BRASE, CONSTANCE LYNNETTE (MA)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:LYNNETTE
Last Name:BRASE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:LYNETTE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:711 BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2138
Mailing Address - Country:US
Mailing Address - Phone:719-384-5446
Mailing Address - Fax:719-384-5672
Practice Address - Street 1:109 LEE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-3717
Practice Address - Country:US
Practice Address - Phone:719-336-0478
Practice Address - Fax:719-384-8411
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor