Provider Demographics
NPI:1821781808
Name:DEHAVEN, BRANDON ALLEN
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:ALLEN
Last Name:DEHAVEN
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 1:1360 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-3013
Mailing Address - Country:US
Mailing Address - Phone:760-872-2590
Mailing Address - Fax:
Practice Address - Street 1:1360 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3013
Practice Address - Country:US
Practice Address - Phone:760-872-2590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor