Basic Information
| Provider Information | |||||||||
| NPI: | 1164670709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRASE | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | LYNNETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | CONSTANCE | ||||||||
| OtherMiddleName: | LYNETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 711 BARNES AVE | ||||||||
| Address2: | |||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193845446 | ||||||||
| FaxNumber: | 7193845672 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 LEE AVE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | LAMAR | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810523717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193360478 | ||||||||
| FaxNumber: | 7193848411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2008 | ||||||||
| LastUpdateDate: | 09/08/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.