Healthcare Provider Details

I. General information

NPI: 1780078493
Provider Name (Legal Business Name): BRANDON W COLEMAN LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 E THOMAS RD
PHOENIX AZ
85016-8134
US

IV. Provider business mailing address

3003 N CENTRAL AVE STE 200
PHOENIX AZ
85012-2914
US

V. Phone/Fax

Practice location:
  • Phone: 602-302-7812
  • Fax: 602-258-6140
Mailing address:
  • Phone: 602-685-6000
  • Fax: 602-685-6002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-15030
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: