Provider Demographics
NPI:1407270598
Name:MISSOURI, BRANDI
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:MISSOURI
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 1:4521 MARCONI AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-4313
Mailing Address - Country:US
Mailing Address - Phone:916-494-2330
Mailing Address - Fax:
Practice Address - Street 1:7000 FRANKLIN BLVD
Practice Address - Street 2:SUITE 625
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-1820
Practice Address - Country:US
Practice Address - Phone:916-388-9418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARRW6911101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)