Provider Demographics
NPI:1649599739
Name:DALE, BRANDY M (CPRS, ST-C, STNA)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:M
Last Name:DALE
Suffix:
Gender:
Credentials:CPRS, ST-C, STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 MAJESTIC DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-8925
Mailing Address - Country:US
Mailing Address - Phone:513-279-8222
Mailing Address - Fax:
Practice Address - Street 1:573 MAJESTIC DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-8925
Practice Address - Country:US
Practice Address - Phone:513-279-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X, 374U00000X, 171M00000X, 106S00000X, 374700000X
OH400865580209376K00000X
OH0001415175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist
No374700000XNursing Service Related ProvidersTechnician