Healthcare Provider Details

I. General information

NPI: 1780761130
Provider Name (Legal Business Name): GAIL CASSANDRA BROTHERS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6421 CAMP BOWIE BLVD SUITE 306
FORT WORTH TX
76116-5401
US

IV. Provider business mailing address

PO BOX 101011
FORT WORTH TX
76185-1011
US

V. Phone/Fax

Practice location:
  • Phone: 817-689-4744
  • Fax: 817-207-0704
Mailing address:
  • Phone: 817-689-4744
  • Fax: 817-207-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25595
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number25595
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: