Healthcare Provider Details

I. General information

NPI: 1710692991
Provider Name (Legal Business Name): BRANDON GESCHEIDLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/23/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 S SEPULVEDA BLVD APT 2903
LOS ANGELES CA
90064-1872
US

IV. Provider business mailing address

2435 S SEPULVEDA BLVD APT 2903
LOS ANGELES CA
90064-1872
US

V. Phone/Fax

Practice location:
  • Phone: 847-212-6142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number132103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: