Provider Demographics
NPI:1285237461
Name:MEDLEY, BRANDON LAWRENCE (LMSW)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:LAWRENCE
Last Name:MEDLEY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 CAMINO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4851
Mailing Address - Country:US
Mailing Address - Phone:610-620-4091
Mailing Address - Fax:
Practice Address - Street 1:301 S CAMINO DEL PUEBLO
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-6276
Practice Address - Country:US
Practice Address - Phone:505-867-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-11397104100000X
1041C0700X
NMSWB-2024-05801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker