Provider Demographics
NPI:1679263032
Name:LARA, BRANDIE MARIE
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:MARIE
Last Name:LARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 DALMATION PL NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-7567
Mailing Address - Country:US
Mailing Address - Phone:505-712-7270
Mailing Address - Fax:
Practice Address - Street 1:4716 DALMATION PL NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-7567
Practice Address - Country:US
Practice Address - Phone:505-712-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician