Provider Demographics
NPI:1164728309
Name:BRACKENBURY, EDWARD V (MFT)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:V
Last Name:BRACKENBURY
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 E GREENWICH PL
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-3417
Mailing Address - Country:US
Mailing Address - Phone:650-324-0619
Mailing Address - Fax:650-327-9521
Practice Address - Street 1:1220 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4262
Practice Address - Country:US
Practice Address - Phone:659-324-0619
Practice Address - Fax:650-327-9521
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-06
Last Update Date:2011-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 7563106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 7563OtherMFT