Provider Demographics
NPI:1598337677
Name:BRANDON MANSOURI MARRIAGE & FAMILY THERAPIST, INC.
Entity Type:Organization
Organization Name:BRANDON MANSOURI MARRIAGE & FAMILY THERAPIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-259-2779
Mailing Address - Street 1:4344 LATHAM ST STE 110
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-1773
Mailing Address - Country:US
Mailing Address - Phone:716-259-2779
Mailing Address - Fax:
Practice Address - Street 1:4344 LATHAM ST STE 110
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1773
Practice Address - Country:US
Practice Address - Phone:716-259-2779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty