Provider Demographics
NPI:1396494332
Name:BRANNON, MICAH LARSEN (SUDPT)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:LARSEN
Last Name:BRANNON
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 ORONDO AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2800
Mailing Address - Country:US
Mailing Address - Phone:509-662-6000
Mailing Address - Fax:509-664-4590
Practice Address - Street 1:819 N MILLER ST STE 1B
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6604
Practice Address - Country:US
Practice Address - Phone:509-664-4592
Practice Address - Fax:509-664-3594
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61152752101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)