Provider Demographics
NPI:1023723475
Name:BRANDON, LARRY J
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:J
Last Name:BRANDON
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 1:1575 W UNIVERSITY DR STE 111
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-3283
Mailing Address - Country:US
Mailing Address - Phone:480-687-9009
Mailing Address - Fax:
Practice Address - Street 1:1575 W UNIVERSITY DR STE 111
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-3283
Practice Address - Country:US
Practice Address - Phone:480-687-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
AZCSLG12168101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health