Provider Demographics
NPI:1669744397
Name:PACHECO GALLEGOS, BRANDIE
Entity type:Individual
Prefix:
First Name:BRANDIE
Middle Name:
Last Name:PACHECO GALLEGOS
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 1:10031 CORRAL GATE LN SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-7257
Mailing Address - Country:US
Mailing Address - Phone:505-350-4997
Mailing Address - Fax:
Practice Address - Street 1:1101 LOPEZ RD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3954
Practice Address - Country:US
Practice Address - Phone:505-239-6404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator