Provider Demographics
NPI:1790386142
Name:PHILLIPS, BRANDON
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:PHILLIPS
Suffix:
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 1:2428 W REYNOLDS AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAILIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4554
Mailing Address - Country:US
Mailing Address - Phone:360-330-9044
Mailing Address - Fax:360-736-3139
Practice Address - Street 1:2428 W REYNOLDS AVE
Practice Address - Street 2:
Practice Address - City:CENTALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4554
Practice Address - Country:US
Practice Address - Phone:360-330-9044
Practice Address - Fax:360-736-3139
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health