Healthcare Provider Details

I. General information

NPI: 1013641513
Provider Name (Legal Business Name): BRANDON RIVERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4303 W VILLAGE AVE APT 3002
CAMP SPRINGS MD
20746-5232
US

IV. Provider business mailing address

2110 PRIEST BRIDGE DR STE 1
CROFTON MD
21114-2472
US

V. Phone/Fax

Practice location:
  • Phone: 202-630-4446
  • Fax:
Mailing address:
  • Phone: 443-937-7089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number07418
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: