Provider Demographics
NPI:1215360862
Name:BREWER, DEATRA
Entity Type:Individual
Prefix:MS
First Name:DEATRA
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4991 E MCKINLEY AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1966
Mailing Address - Country:US
Mailing Address - Phone:559-981-2143
Mailing Address - Fax:
Practice Address - Street 1:4991 E MCKINLEY AVE STE 112
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1966
Practice Address - Country:US
Practice Address - Phone:559-981-2143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510488527101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1962637512OtherMEDI CAL