Healthcare Provider Details

I. General information

NPI: 1023141116
Provider Name (Legal Business Name): BRANNON & BRANNON PSYCHOLOGICAL SERVICES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 TREJO STREET SUITE 100
REXBURG ID
83440
US

IV. Provider business mailing address

534 TREJO STREET SUITE 100
REXBURG ID
83440
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-3776
  • Fax: 208-356-9498
Mailing address:
  • Phone: 208-356-3776
  • Fax: 208-356-9498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES M BRANNON
Title or Position: SECRETARY
Credential: ED.D.
Phone: 208-356-3776