Basic Information
| Provider Information | |||||||||
| NPI: | 1790195998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAPLA | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | ALISSA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSY | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLS | ||||||||
| OtherFirstName: | BROOKE | ||||||||
| OtherMiddleName: | ALISSA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | INTERNAL MEDICINE | ||||||||
| Address2: | 401 SAN MATEO BLVD SE | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054627333 | ||||||||
| FaxNumber: | 5054627440 | ||||||||
| Practice Location | |||||||||
| Address1: | INTERNAL MEDICINE | ||||||||
| Address2: | 401 SAN MATEO BLVD SE | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054627333 | ||||||||
| FaxNumber: | 5054627440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2014 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 10098 | NE | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103T00000X | 1635 | NM | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.