Provider Demographics
NPI:1215393483
Name:PHILLIPS, BRANDEN DAVID (LICSW)
Entity Type:Individual
Prefix:
First Name:BRANDEN
Middle Name:DAVID
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 SCOTT AVE N
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2745
Mailing Address - Country:US
Mailing Address - Phone:952-322-0836
Mailing Address - Fax:
Practice Address - Street 1:3241 SCOTT AVE N
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-2745
Practice Address - Country:US
Practice Address - Phone:952-322-0836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN199351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical