Basic Information
Provider Information | |||||||||
NPI: | 1588839187 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | CONNIE | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 511 WELSHIRE ST | ||||||||
Address2: |   | ||||||||
City: | CARLSBAD | ||||||||
State: | NM | ||||||||
PostalCode: | 882203342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5054009078 | ||||||||
FaxNumber: | 5058300040 | ||||||||
Practice Location | |||||||||
Address1: | 914 N CANAL ST | ||||||||
Address2: |   | ||||||||
City: | CARLSBAD | ||||||||
State: | NM | ||||||||
PostalCode: | 882205110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5758874649 | ||||||||
FaxNumber: | 5758879579 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2008 | ||||||||
LastUpdateDate: | 01/05/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | T-0119811 | NM | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.