Provider Demographics
NPI:1679841779
Name:MASSENGALE CUELLAR, BRANDI LEE (CATC)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:LEE
Last Name:MASSENGALE CUELLAR
Suffix:
Gender:F
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 HERMOSA CT
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-2932
Mailing Address - Country:US
Mailing Address - Phone:805-748-0067
Mailing Address - Fax:
Practice Address - Street 1:2494 PENNINGTON CREEK RD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-7841
Practice Address - Country:US
Practice Address - Phone:805-782-7258
Practice Address - Fax:805-543-2599
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACATC # 102505101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)