Provider Demographics
NPI:1356585848
Name:BRANDT, KENNETH O
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:O
Last Name:BRANDT
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 1:44 E SIERRA MADRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024-2565
Mailing Address - Country:US
Mailing Address - Phone:626-836-2101
Mailing Address - Fax:
Practice Address - Street 1:330 EAST LIVE OAK AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-5611
Practice Address - Country:US
Practice Address - Phone:626-821-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 106761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical