Provider Demographics
NPI:1376904896
Name:EASTON, BRANDY
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:EASTON
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 1:5201 VENICE AVE NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2337
Mailing Address - Country:US
Mailing Address - Phone:505-433-7703
Mailing Address - Fax:
Practice Address - Street 1:5201 VENICE AVE NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2337
Practice Address - Country:US
Practice Address - Phone:505-433-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0173761101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health