Provider Demographics
NPI:1407940588
Name:BRANDT, JEANETTE D (LPC)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:D
Last Name:BRANDT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 W BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-3271
Mailing Address - Country:US
Mailing Address - Phone:505-461-6080
Mailing Address - Fax:
Practice Address - Street 1:214 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-2223
Practice Address - Country:US
Practice Address - Phone:505-461-6080
Practice Address - Fax:505-461-4802
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1266101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89534077Medicaid