Provider Demographics
NPI:1659950723
Name:BREAULT, BRANDON JADE (LMFT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JADE
Last Name:BREAULT
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13636 VENTURA BLVD # 234
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3700
Mailing Address - Country:US
Mailing Address - Phone:646-239-9257
Mailing Address - Fax:
Practice Address - Street 1:3900 GLENRIDGE DR
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-4645
Practice Address - Country:US
Practice Address - Phone:646-239-9257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist