Provider Demographics
NPI:1780282012
Name:BROTHERS, ANNIE (PMSW)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:BROTHERS
Suffix:
Gender:F
Credentials:PMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N CORONADO AVE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2700
Mailing Address - Country:US
Mailing Address - Phone:505-692-4473
Mailing Address - Fax:
Practice Address - Street 1:1911 5TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5403
Practice Address - Country:US
Practice Address - Phone:505-955-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMX-11723Medicaid