Provider Demographics
NPI:1578707857
Name:RADCLIFFE, BRANDON SHANE (BS, MHP)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:SHANE
Last Name:RADCLIFFE
Suffix:
Gender:M
Credentials:BS, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BOGEY LN
Mailing Address - Street 2:
Mailing Address - City:MAKANDA
Mailing Address - State:IL
Mailing Address - Zip Code:62958-2766
Mailing Address - Country:US
Mailing Address - Phone:931-801-6561
Mailing Address - Fax:
Practice Address - Street 1:408 E VINE ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-1612
Practice Address - Country:US
Practice Address - Phone:618-658-2611
Practice Address - Fax:618-658-2501
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health