Provider Demographics
NPI:1588843056
Name:BRENDA L WOLFE PHD PC
Entity Type:Organization
Organization Name:BRENDA L WOLFE PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-884-5700
Mailing Address - Street 1:2200 GRANDE SE BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1655
Mailing Address - Country:US
Mailing Address - Phone:505-884-5700
Mailing Address - Fax:505-884-5701
Practice Address - Street 1:2200 GRANDE SE BLVD
Practice Address - Street 2:STE B
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1655
Practice Address - Country:US
Practice Address - Phone:505-884-5700
Practice Address - Fax:505-884-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0790103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM100864Medicaid
NMNM00JA81OtherBLUE CROSS/BLUE SHIELD
NMNM100864Medicaid
NM=========OtherCHAMP VA
NM800521014Medicare PIN