Provider Demographics
NPI:1063133882
Name:FANK, BRIANNA (LCSW)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:FANK
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 1:1040 SAKELARES BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-3819
Mailing Address - Country:US
Mailing Address - Phone:505-876-1890
Mailing Address - Fax:
Practice Address - Street 1:1040 SAKELARES BLVD
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-3819
Practice Address - Country:US
Practice Address - Phone:505-876-1890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2025-00571041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical