Provider Demographics
NPI:1649734955
Name:TWEEDY, BRANDON (ICADC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:TWEEDY
Suffix:
Gender:M
Credentials:ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W PEACHTREE ST NW UNIT 1116
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-3547
Mailing Address - Country:US
Mailing Address - Phone:757-746-3812
Mailing Address - Fax:
Practice Address - Street 1:400 W PEACHTREE ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-3536
Practice Address - Country:US
Practice Address - Phone:757-746-3812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1280101YA0400X
GAE088101YA0400X
GA173834101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty