Provider Demographics
NPI:1659152833
Name:BRANDON, JOHN M JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:BRANDON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 S MAIN ST STE L
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2404
Mailing Address - Country:US
Mailing Address - Phone:808-681-2718
Mailing Address - Fax:
Practice Address - Street 1:298 S MAIN ST STE L
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2404
Practice Address - Country:US
Practice Address - Phone:808-681-2718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61492266106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician