=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013234418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON EDWARD TOMLIN LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2010
-----------------------------------------------------
Last Update Date | 08/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 TYDD ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-1284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-441-1624
-----------------------------------------------------
Fax | 707-441-1253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1275 8TH ST
-----------------------------------------------------
City | ARCATA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95521-5770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-826-8633
-----------------------------------------------------
Fax | 707-826-8638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 104793
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------