Provider Demographics
NPI:1457780496
Name:BRANCH, PHEYNELL (AAS, CSAC,CSIT)
Entity Type:Individual
Prefix:MRS
First Name:PHEYNELL
Middle Name:
Last Name:BRANCH
Suffix:
Gender:F
Credentials:AAS, CSAC,CSIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6737 W WASHINGTON ST STE 2210
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-5650
Mailing Address - Country:US
Mailing Address - Phone:414-777-1570
Mailing Address - Fax:
Practice Address - Street 1:1650 WASINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403
Practice Address - Country:US
Practice Address - Phone:262-633-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15662-132101YA0400X
WI15476-133101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)