Provider Demographics
NPI:1922720861
Name:ZAMORA, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:ZAMORA
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:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:SPRINGER
Mailing Address - State:NM
Mailing Address - Zip Code:87747-0446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:802 3RD STREET
Practice Address - Street 2:
Practice Address - City:SPRINGER
Practice Address - State:NM
Practice Address - Zip Code:87747
Practice Address - Country:US
Practice Address - Phone:505-808-5576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 1041C0700X
NMCMH0192861174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes172V00000XOther Service ProvidersCommunity Health Worker
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68589344Medicaid