Provider Demographics
NPI:1407621881
Name:MACKISON, BRANDI (RBT)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:MACKISON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2349
Mailing Address - Country:US
Mailing Address - Phone:888-515-1793
Mailing Address - Fax:
Practice Address - Street 1:9165 OTIS AVE STE 221
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2316
Practice Address - Country:US
Practice Address - Phone:888-515-1793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-23-304151106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician