Provider Demographics
NPI:1720103823
Name:BRACKEN, JOELLE LIZETTE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JOELLE
Middle Name:LIZETTE
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MONTIANO LOOP SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-8769
Mailing Address - Country:US
Mailing Address - Phone:575-910-8102
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:505-627-2562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2569051041S0200X
NMSWB-2023-08061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1720103823.Medicaid
NM50423835Medicaid