Provider Demographics
NPI:1710611991
Name:BANDA, BRISA
Entity Type:Individual
Prefix:
First Name:BRISA
Middle Name:
Last Name:BANDA
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 1:3876 HAWKINS ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4539
Mailing Address - Country:US
Mailing Address - Phone:505-508-0865
Mailing Address - Fax:
Practice Address - Street 1:1201 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-7258
Practice Address - Country:US
Practice Address - Phone:505-508-0865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician