Provider Demographics
NPI:1528359759
Name:PHILLIPS, BRANDE L
Entity Type:Individual
Prefix:
First Name:BRANDE
Middle Name:L
Last Name:PHILLIPS
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 1:11951 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1855
Mailing Address - Country:US
Mailing Address - Phone:760-900-2279
Mailing Address - Fax:760-900-2279
Practice Address - Street 1:11951 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1855
Practice Address - Country:US
Practice Address - Phone:760-900-2279
Practice Address - Fax:760-900-2279
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
CAIMF 70201106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No174H00000XOther Service ProvidersHealth Educator