Healthcare Provider Details

I. General information

NPI: 1508533746
Provider Name (Legal Business Name): MICHAEL JASON BRANNIGAN CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 LIBERTY ST
BATH NY
14810-1508
US

IV. Provider business mailing address

113 MAPLE HTS
BATH NY
14810-1013
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-2156
  • Fax:
Mailing address:
  • Phone: 607-329-1026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number36354
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: