Healthcare Provider Details

I. General information

NPI: 1811031669
Provider Name (Legal Business Name): BRANDON HAROLD PRINTUP L.P.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1074 NORTH DECATUR RD SUITE 145
DECATUR GA
30030
US

IV. Provider business mailing address

939 PORTER RD
DECATUR GA
30032-1729
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-6677
  • Fax:
Mailing address:
  • Phone: 404-292-9510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number004266
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: