Provider Demographics
NPI:1770236937
Name:BOWER, BREANNE
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:BOWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:
Other - Last Name:SOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 LASER RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4517
Mailing Address - Country:US
Mailing Address - Phone:505-962-1242
Mailing Address - Fax:
Practice Address - Street 1:500 LASER RD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4517
Practice Address - Country:US
Practice Address - Phone:505-962-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM403947103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool