Provider Demographics
NPI:1902335821
Name:ANTHONY, BRIAN (LCSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 JUAN TABO BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1818
Mailing Address - Country:US
Mailing Address - Phone:505-317-3792
Mailing Address - Fax:
Practice Address - Street 1:2424 JUAN TABO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1818
Practice Address - Country:US
Practice Address - Phone:505-317-3792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-113771041C0700X
WASC606995731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical