MEDICARE: RYAN ALLEN BRABRAND LCAS-A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS-23891	NC

General Provider Information

NPI Number	:	1457865065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN ALLEN BRABRAND LCAS-A

Provider Business Mailing Address
First Line	:	321 S 5TH AVE APT B
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28401-4518
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1221 FLORAL PKWY STE 207
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6235
Country	:	US
Telephone Number	:	910-465-8972
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2017
Last Update Date	:	11/20/2017

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