Provider Demographics
NPI:1417578071
Name:BRANDY, IYEA
Entity Type:Individual
Prefix:
First Name:IYEA
Middle Name:
Last Name:BRANDY
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 1:1886 LOGAN RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8173
Mailing Address - Country:US
Mailing Address - Phone:973-216-1066
Mailing Address - Fax:
Practice Address - Street 1:1903 PHOENIX BLVD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5754
Practice Address - Country:US
Practice Address - Phone:404-821-5259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007362101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty