Provider Demographics
NPI:1265274203
Name:BRANDON, CHARLES JR
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BRANDON
Suffix:JR
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 1:1120 ONTARIO ST APT 203
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1954
Mailing Address - Country:US
Mailing Address - Phone:773-977-6880
Mailing Address - Fax:
Practice Address - Street 1:1120 ONTARIO ST APT 203
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1954
Practice Address - Country:US
Practice Address - Phone:773-977-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171400000XOther Service ProvidersHealth & Wellness Coach