Healthcare Provider Details

I. General information

NPI: 1104565548
Provider Name (Legal Business Name): BRANSON MICHAEL FREEMAN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9415 E HARRY ST STE 800
WICHITA KS
67207-5084
US

IV. Provider business mailing address

9415 E HARRY ST STE 800
WICHITA KS
67207-5084
US

V. Phone/Fax

Practice location:
  • Phone: 316-652-2590
  • Fax:
Mailing address:
  • Phone: 316-652-2590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12542
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: