Provider Demographics
NPI:1598387078
Name:DE LA GUARDIA, BRANDON RENE
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:RENE
Last Name:DE LA GUARDIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5872 EMBEE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3512
Mailing Address - Country:US
Mailing Address - Phone:408-674-0663
Mailing Address - Fax:
Practice Address - Street 1:1500 E HAMILTON AVE STE 105
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0834
Practice Address - Country:US
Practice Address - Phone:408-772-3775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA075-39916DMedicaid