Provider Demographics
NPI:1558806604
Name:STEVENS, BRANDY (BA, MS, CDC 1)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:BA, MS, CDC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 S KNIK GOOSE BAY RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8062
Mailing Address - Country:US
Mailing Address - Phone:907-313-1333
Mailing Address - Fax:
Practice Address - Street 1:591 S KNIK GOOSE BAY RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8062
Practice Address - Country:US
Practice Address - Phone:907-313-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 174400000X
AK172054101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist