Provider Demographics
NPI:1780629063
Name:BRUMAGE, JOAN (LISW)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:BRUMAGE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-307-6630
Mailing Address - Fax:405-307-6660
Practice Address - Street 1:1213 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6725
Practice Address - Country:US
Practice Address - Phone:575-921-1616
Practice Address - Fax:575-434-3253
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI05349101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM67659721Medicaid
NM67659721Medicaid