Provider Demographics
NPI:1073011706
Name:BRANCHES THERAPY NETWORK, PC
Entity Type:Organization
Organization Name:BRANCHES THERAPY NETWORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:GREY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCPC
Authorized Official - Phone:833-227-2624
Mailing Address - Street 1:26 DEER TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-6817
Mailing Address - Country:US
Mailing Address - Phone:833-227-2624
Mailing Address - Fax:
Practice Address - Street 1:5400 DURANGO TRL
Practice Address - Street 2:
Practice Address - City:PLEASANT PLAINS
Practice Address - State:IL
Practice Address - Zip Code:62677-4060
Practice Address - Country:US
Practice Address - Phone:217-836-4642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-29
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-012183101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty