Provider Demographics
NPI:1275838989
Name:BRAIN PRACTICE, LLC
Entity Type:Organization
Organization Name:BRAIN PRACTICE, LLC
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRANT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:816-351-6997
Mailing Address - Street 1:39055 E STATE HIGHWAY 146
Mailing Address - Street 2:
Mailing Address - City:GILMAN CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64642-7215
Mailing Address - Country:US
Mailing Address - Phone:816-351-6997
Mailing Address - Fax:
Practice Address - Street 1:39055 E STATE HIGHWAY 146
Practice Address - Street 2:
Practice Address - City:GILMAN CITY
Practice Address - State:MO
Practice Address - Zip Code:64642-7215
Practice Address - Country:US
Practice Address - Phone:816-351-6997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007000444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty