Provider Demographics
NPI:1295368017
Name:BRANNON, TAINISE
Entity Type:Individual
Prefix:
First Name:TAINISE
Middle Name:
Last Name:BRANNON
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 1:561 E LAKE DR # 561
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-3874
Mailing Address - Country:US
Mailing Address - Phone:334-524-5436
Mailing Address - Fax:
Practice Address - Street 1:137 JOHNSON FERRY RD STE 2170
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4948
Practice Address - Country:US
Practice Address - Phone:855-543-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician