Basic Information
| Provider Information | |||||||||
| NPI: | 1255779872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATCH | ||||||||
| FirstName: | BRECKON | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 OAK ST | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753233354 | ||||||||
| FaxNumber: | 5755232299 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 OAK ST | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753233354 | ||||||||
| FaxNumber: | 5755232299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 12/31/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C-09262 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 76104753 | 05 | NM | MEDICAID |