Provider Demographics
NPI:1922553882
Name:HIGGINBOTHAM, BRANDI MARIE
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:MARIE
Last Name:HIGGINBOTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14334 BONEY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-1926
Mailing Address - Country:US
Mailing Address - Phone:904-718-1693
Mailing Address - Fax:
Practice Address - Street 1:31 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3605
Practice Address - Country:US
Practice Address - Phone:704-277-1884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-51034106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL705825Medicaid