Provider Demographics
NPI:1669626297
Name:BRICKLEY, MAUREEN B (LPC C)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:B
Last Name:BRICKLEY
Suffix:
Gender:F
Credentials:LPC C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 STATE HIGHWAY 14 N
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:NM
Mailing Address - Zip Code:87010-9746
Mailing Address - Country:US
Mailing Address - Phone:215-803-5261
Mailing Address - Fax:
Practice Address - Street 1:6612 GULTON CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4407
Practice Address - Country:US
Practice Address - Phone:505-888-1686
Practice Address - Fax:505-888-1683
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000657101YP2500X
NMCCMH0146921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61581569Medicaid