=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396611729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. BRANDON ALLEN TATE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2025
-----------------------------------------------------
Last Update Date | 10/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 CIRCLE WAY ST STE 110
-----------------------------------------------------
City | LAKE JACKSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77566-5239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-217-1789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2018 W RUNDBERG LN APT 20A
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-5974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 90424
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------