Provider Demographics
NPI:1114631314
Name:NGUYEN, BRANDON THANH
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14419 BLACK LAKE PRESERVE ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5212
Mailing Address - Country:US
Mailing Address - Phone:317-750-7090
Mailing Address - Fax:
Practice Address - Street 1:601 S LAKE DESTINY RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7226
Practice Address - Country:US
Practice Address - Phone:800-394-7195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician