Healthcare Provider Details

I. General information

NPI: 1689080707
Provider Name (Legal Business Name): BRANDON PELLATON LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 5TH ST SW
WILLMAR MN
56201-3216
US

IV. Provider business mailing address

PO BOX 1810
WILLMAR MN
56201-1810
US

V. Phone/Fax

Practice location:
  • Phone: 320-214-9692
  • Fax: 320-214-9924
Mailing address:
  • Phone: 320-214-9692
  • Fax: 320-214-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21177
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: