Provider Demographics
NPI:1598394660
Name:BRANDIMORE, ROBERT WADE (LBSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WADE
Last Name:BRANDIMORE
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0001
Mailing Address - Country:US
Mailing Address - Phone:602-528-7135
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:291 W CASA BLANCA RD.
Practice Address - Street 2:BLDG. 7
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147
Practice Address - Country:US
Practice Address - Phone:520-562-3323
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLBSW-0959104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker