Healthcare Provider Details

I. General information

NPI: 1205115102
Provider Name (Legal Business Name): BRANDON DELLARIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 OAKLAND DR
PORTAGE MI
49024-1118
US

IV. Provider business mailing address

601 FOREST ST
KALAMAZOO MI
49008-1309
US

V. Phone/Fax

Practice location:
  • Phone: 269-323-1954
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: