Healthcare Provider Details

I. General information

NPI: 1295394419
Provider Name (Legal Business Name): WILLIE CHARLES BRANTLEY RECOVERY COACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 BREWSTER ST
HOUSTON TX
77026-4446
US

IV. Provider business mailing address

10106 FONVILLE DR
HOUSTON TX
77075-3304
US

V. Phone/Fax

Practice location:
  • Phone: 512-293-2526
  • Fax:
Mailing address:
  • Phone: 832-858-3024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1011-0319
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: