Healthcare Provider Details

I. General information

NPI: 1508577164
Provider Name (Legal Business Name): BRANDON HULST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W BRIGGSMORE AVE STE I
MODESTO CA
95350-4234
US

IV. Provider business mailing address

200 W BRIGGSMORE AVE STE I
MODESTO CA
95350-4234
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1476
  • Fax: 209-526-0908
Mailing address:
  • Phone: 209-526-1476
  • Fax: 209-526-0908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number16023
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: