Basic Information
| Provider Information | |||||||||
| NPI: | 1780629063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUMAGE | ||||||||
| FirstName: | JOAN | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1330 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730701330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053076630 | ||||||||
| FaxNumber: | 4053076660 | ||||||||
| Practice Location | |||||||||
| Address1: | 1213 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | ALAMOGORDO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883106725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5759211616 | ||||||||
| FaxNumber: | 5754343253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 04/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | I05349 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 67659721 | 05 | NM | MEDICAID |