Provider Demographics
NPI:1164735767
Name:DEVASIER, BRANDON CHAARLES (MHPP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:CHAARLES
Last Name:DEVASIER
Suffix:
Gender:M
Credentials:MHPP
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:CHARLES
Other - Last Name:DEVASIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-6614
Mailing Address - Country:US
Mailing Address - Phone:501-472-9833
Mailing Address - Fax:501-687-0839
Practice Address - Street 1:1815 PLEASANT GROVE RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-7870
Practice Address - Country:US
Practice Address - Phone:870-933-6886
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator