Healthcare Provider Details

I. General information

NPI: 1497678502
Provider Name (Legal Business Name): BRANDON GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16519 VICTOR ST STE 302
VICTORVILLE CA
92395-3967
US

IV. Provider business mailing address

16519 VICTOR ST STE 302
VICTORVILLE CA
92395-3967
US

V. Phone/Fax

Practice location:
  • Phone: 760-305-9677
  • Fax: 760-269-8079
Mailing address:
  • Phone: 760-305-9677
  • Fax: 760-269-8079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: