Healthcare Provider Details

I. General information

NPI: 1265274203
Provider Name (Legal Business Name): CHARLES BRANDON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 ONTARIO ST APT 203
OAK PARK IL
60302-1954
US

IV. Provider business mailing address

1120 ONTARIO ST APT 203
OAK PARK IL
60302-1954
US

V. Phone/Fax

Practice location:
  • Phone: 773-977-6880
  • Fax:
Mailing address:
  • Phone: 773-977-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: