Provider Demographics
NPI:1831065374
Name:DICK, BRANDON DAVID
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:DAVID
Last Name:DICK
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 1:4351 STONEBRIDGE DR SW APT 1
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-4165
Mailing Address - Country:US
Mailing Address - Phone:407-455-8776
Mailing Address - Fax:
Practice Address - Street 1:23800 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-7710
Practice Address - Country:US
Practice Address - Phone:412-927-8461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-13
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI200098135320106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician