Provider Demographics
NPI:1366564817
Name:BRANDSER, MICHELLE RAE (MAC, LPCC, LADAC)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RAE
Last Name:BRANDSER
Suffix:
Gender:F
Credentials:MAC, LPCC, LADAC
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 1830
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-1830
Mailing Address - Country:US
Mailing Address - Phone:505-368-1467
Mailing Address - Fax:505-368-1452
Practice Address - Street 1:PINON AND COTTONWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-1438
Practice Address - Fax:505-368-1438
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007179251S00000X
NM0141981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health