=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326122656
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KANDI K BRELSFORD MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 03/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 S EDWIN C MOSES BLVD SAMARITAN BEHAVIORAL HEALTH, INC.,
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45417-3424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-984-1800
-----------------------------------------------------
Fax | 513-984-4909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 S EDWIN C MOSES BLVD, 4TH FLOOR NW BLDG SAMARITAN BEHAVIORAL HEALTH INC
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45417-3424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-734-8333
-----------------------------------------------------
Fax | 937-734-4343
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I528
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.0000528-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------