Healthcare Provider Details

I. General information

NPI: 1164002044
Provider Name (Legal Business Name): MR. BRANDON TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10721 W CAPITOL DR STE 210
WAUWATOSA WI
53222-1210
US

IV. Provider business mailing address

10721 W CAPITOL DR STE 210
WAUWATOSA WI
53222-1210
US

V. Phone/Fax

Practice location:
  • Phone: 414-988-3079
  • Fax:
Mailing address:
  • Phone: 414-988-3079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19183-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: