Provider Demographics
NPI:1588821730
Name:BRAECKLEIN, TRISHA (BCBA)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:BRAECKLEIN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PERKINS DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3248
Mailing Address - Country:US
Mailing Address - Phone:575-526-6682
Mailing Address - Fax:575-523-7254
Practice Address - Street 1:1675 HICKORY LOOP
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-6587
Practice Address - Country:US
Practice Address - Phone:575-652-3155
Practice Address - Fax:505-715-4958
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-17-26155103K00000X
NVCBIT051412103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst