Provider Demographics
NPI:1346888757
Name:MILLER, BRANDON PATRICK
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:PATRICK
Last Name:MILLER
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 1:2334 CHILCOTE TER
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33981-1000
Mailing Address - Country:US
Mailing Address - Phone:860-837-3483
Mailing Address - Fax:
Practice Address - Street 1:655 N INDIANA AVE UNIT A
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-2756
Practice Address - Country:US
Practice Address - Phone:941-999-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-107878106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician