Provider Demographics
NPI:1760900096
Name:BRAKE, RITA (MA LMHC)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:BRAKE
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ARROYO LN APT B
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3213
Mailing Address - Country:US
Mailing Address - Phone:505-695-9674
Mailing Address - Fax:
Practice Address - Street 1:1460 TRINITY DR STE 4
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-4107
Practice Address - Country:US
Practice Address - Phone:505-983-8225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0191181101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional