Provider Demographics
NPI:1073762415
Name:J PHYLLIS BRANNEN LCSW CAP
Entity Type:Organization
Organization Name:J PHYLLIS BRANNEN LCSW CAP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:PHYLLIS
Authorized Official - Last Name:BRANNEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW CAP
Authorized Official - Phone:321-953-3225
Mailing Address - Street 1:1503 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3120
Mailing Address - Country:US
Mailing Address - Phone:321-953-3225
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2553L101YA0400X
FLSW62391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty