Provider Demographics
NPI:1285186775
Name:BRANHAM, DOUGLAS
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:BRANHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 SENECA AVE
Mailing Address - Street 2:PO BOX 112
Mailing Address - City:BYESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43723-1364
Mailing Address - Country:US
Mailing Address - Phone:740-685-1610
Mailing Address - Fax:888-283-1321
Practice Address - Street 1:209 SENECA AVE
Practice Address - Street 2:
Practice Address - City:BYESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43723-1364
Practice Address - Country:US
Practice Address - Phone:740-685-1610
Practice Address - Fax:888-283-1321
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0007370104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker