Provider Demographics
NPI:1780761130
Name:BROTHERS, GAIL CASSANDRA (PHD)
Entity type:Individual
Prefix:DR
First Name:GAIL
Middle Name:CASSANDRA
Last Name:BROTHERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 101011
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76185-1011
Mailing Address - Country:US
Mailing Address - Phone:817-689-4744
Mailing Address - Fax:817-207-0704
Practice Address - Street 1:6421 CAMP BOWIE BLVD
Practice Address - Street 2:SUITE 306
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5401
Practice Address - Country:US
Practice Address - Phone:817-689-4744
Practice Address - Fax:817-207-0704
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25595103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1172603-04Medicaid
TXS36833Medicare UPIN
TX1172603-04Medicaid