Provider Demographics
NPI:1639420011
Name:GHOLSON, BRANDON TERRELL-ROBERT (M,S,)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:TERRELL-ROBERT
Last Name:GHOLSON
Suffix:
Gender:M
Credentials:M,S,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-1218
Mailing Address - Country:US
Mailing Address - Phone:617-790-4908
Mailing Address - Fax:
Practice Address - Street 1:313 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02210-1218
Practice Address - Country:US
Practice Address - Phone:617-790-4908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health