Individual
BRENT LANE CLOVIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LMSW
Contact information
Practice address
2960 RODEO PARK DR W, SANTA FE, NM 87505-6351
(505) 469-6000
Mailing address
2960 RODEO PARK DR W, SANTA FE, NM 87505-6351
(505) 469-6000
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
M-05747
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
78558
—
NM
Enumeration date
12/27/2007
Last updated
05/15/2012
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