Provider Demographics
NPI:1932984119
Name:SLACK, BRANDI LEE
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:LEE
Last Name:SLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1404
Mailing Address - Country:US
Mailing Address - Phone:989-714-1512
Mailing Address - Fax:
Practice Address - Street 1:724 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1900
Practice Address - Country:US
Practice Address - Phone:989-796-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician