Provider Demographics
NPI:1699804286
Name:HOLMGREN, BRAD K (LISW)
Entity type:Individual
Prefix:MR
First Name:BRAD
Middle Name:K
Last Name:HOLMGREN
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 N. CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061
Mailing Address - Country:US
Mailing Address - Phone:505-388-0263
Mailing Address - Fax:
Practice Address - Street 1:900 CENTRAL
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023
Practice Address - Country:US
Practice Address - Phone:505-537-4000
Practice Address - Fax:505-537-3358
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI37611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR8449Medicaid