Provider Demographics
NPI:1063767945
Name:AMY BRASHEAR LLC
Entity type:Organization
Organization Name:AMY BRASHEAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:TERRELL
Authorized Official - Last Name:BRASHEAR
Authorized Official - Suffix:
Authorized Official - Credentials:MC, M DIV
Authorized Official - Phone:505-850-9419
Mailing Address - Street 1:12404 TULAROSA TRL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-7275
Mailing Address - Country:US
Mailing Address - Phone:505-850-9419
Mailing Address - Fax:
Practice Address - Street 1:12805 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2547
Practice Address - Country:US
Practice Address - Phone:505-850-9419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0095411251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM19973748Medicaid