Provider Demographics
NPI:1477581254
Name:BRAZIL, G. WAYNE (MA,LMFTCAL#MFC34554)
Entity Type:Individual
Prefix:MR
First Name:G.
Middle Name:WAYNE
Last Name:BRAZIL
Suffix:
Gender:M
Credentials:MA,LMFTCAL#MFC34554
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 E. CHAPMAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831
Mailing Address - Country:US
Mailing Address - Phone:714-992-4240
Mailing Address - Fax:714-992-5259
Practice Address - Street 1:2501 E. CHAPMAN AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831
Practice Address - Country:US
Practice Address - Phone:714-992-4240
Practice Address - Fax:714-992-5259
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34554106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA34554OtherLICENSE