Provider Demographics
NPI:1174372171
Name:LEWARK, BRANDI
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:LEWARK
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 1:320 OSUNA RD NE STE H4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5955
Mailing Address - Country:US
Mailing Address - Phone:505-345-2778
Mailing Address - Fax:
Practice Address - Street 1:320 OSUNA RD NE STE H4G1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5952
Practice Address - Country:US
Practice Address - Phone:345-277-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0325101YM0800X
NMCTB-2024-0576101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health