Provider Demographics
NPI:1649768813
Name:BRANDON, ILENE
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:BRANDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4999 ASHBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80130-8923
Mailing Address - Country:US
Mailing Address - Phone:303-726-5379
Mailing Address - Fax:
Practice Address - Street 1:8191 SOUTHPARK LN UNIT 201
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-4641
Practice Address - Country:US
Practice Address - Phone:303-726-5379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC0107086101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional