Provider Demographics
NPI:1508981127
Name:PENDERGRAFT, BRANDON S (MS)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:S
Last Name:PENDERGRAFT
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W IMPERIAL HWY
Mailing Address - Street 2:STE 150
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3835
Mailing Address - Country:US
Mailing Address - Phone:800-998-6329
Mailing Address - Fax:
Practice Address - Street 1:915 W IMPERIAL HWY
Practice Address - Street 2:STE 150
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3835
Practice Address - Country:US
Practice Address - Phone:800-998-6329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44890106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPEN1028OtherSTAFF CODE