Provider Demographics
NPI:1386200384
Name:SHINNICK, BRANDY L
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:L
Last Name:SHINNICK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:BRANDY
Other - Middle Name:L
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-0640
Mailing Address - Country:US
Mailing Address - Phone:505-869-5475
Mailing Address - Fax:505-869-4881
Practice Address - Street 1:01 SAGEBRUSH STREET
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022
Practice Address - Country:US
Practice Address - Phone:505-869-5475
Practice Address - Fax:505-869-4881
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0203541101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)