Provider Demographics
NPI:1417652868
Name:PROUTY, BRANDON WILSON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:WILSON
Last Name:PROUTY
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 1:944 LAWELAWE ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96821-1770
Mailing Address - Country:US
Mailing Address - Phone:808-681-2718
Mailing Address - Fax:
Practice Address - Street 1:806 N WEST ST
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-9188
Practice Address - Country:US
Practice Address - Phone:808-681-2718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA23-261073106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician