Provider Demographics
NPI:1881181238
Name:WRIGHT, BRANDON (SSP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 S PEARL ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3099
Mailing Address - Country:US
Mailing Address - Phone:217-248-6081
Mailing Address - Fax:
Practice Address - Street 1:521 S PEARL ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3099
Practice Address - Country:US
Practice Address - Phone:217-248-6081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2351330103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool