Provider Demographics
NPI:1295759199
Name:GAINES, BRANDON ADAM (MSOM, LAC)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:ADAM
Last Name:GAINES
Suffix:
Gender:M
Credentials:MSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 S CREST DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-3312
Mailing Address - Country:US
Mailing Address - Phone:818-961-4046
Mailing Address - Fax:
Practice Address - Street 1:1454 S CREST DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-3312
Practice Address - Country:US
Practice Address - Phone:818-961-4046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 10786171100000X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171100000XOther Service ProvidersAcupuncturist