Healthcare Provider Details

I. General information

NPI: 1881556504
Provider Name (Legal Business Name): KYRA VICTORIA BRANDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KYRA VICTORIA BRANDT HANACEK

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11835 CARMEL MOUNTAIN RD
SAN DIEGO CA
92128-4609
US

IV. Provider business mailing address

4073 GEORGIA ST
SAN DIEGO CA
92103-2609
US

V. Phone/Fax

Practice location:
  • Phone: 619-940-5165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number150396
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: