Provider Demographics
NPI:1891089280
Name:BRAIN INJURY SERVICES OF NEW MEXICO, LLC
Entity Type:Organization
Organization Name:BRAIN INJURY SERVICES OF NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-989-1640
Mailing Address - Street 1:1115 N LUNA CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1656
Mailing Address - Country:US
Mailing Address - Phone:505-989-1640
Mailing Address - Fax:505-989-1640
Practice Address - Street 1:1115 N LUNA CIR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1656
Practice Address - Country:US
Practice Address - Phone:505-989-1640
Practice Address - Fax:505-989-1640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty