Provider Demographics
NPI:1649421389
Name:BRANDON MENTAL HEALTH
Entity Type:Organization
Organization Name:BRANDON MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:813-401-6586
Mailing Address - Street 1:1134 BELL SHOALS RD.
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511
Mailing Address - Country:US
Mailing Address - Phone:813-315-8648
Mailing Address - Fax:813-438-8973
Practice Address - Street 1:1134 BELL SHOALS RD.
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511
Practice Address - Country:US
Practice Address - Phone:813-315-8648
Practice Address - Fax:813-438-8973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW9082251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health