Provider Demographics
NPI:1003993874
Name:BRANNEN, J. PHYLLIS (LCSW, CAP)
Entity Type:Individual
Prefix:MS
First Name:J. PHYLLIS
Middle Name:
Last Name:BRANNEN
Suffix:
Gender:F
Credentials:LCSW, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 SAN JUAN CIR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5419
Mailing Address - Country:US
Mailing Address - Phone:321-255-5426
Mailing Address - Fax:321-953-3252
Practice Address - Street 1:1503 PINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3120
Practice Address - Country:US
Practice Address - Phone:321-953-3225
Practice Address - Fax:321-953-3252
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP 2553101YA0400X
FLSW62391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)