=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811031669
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON HAROLD PRINTUP L.P.C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 10/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1074 NORTH DECATUR RD SUITE 145
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-918-6677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 939 PORTER RD
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30032-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-292-9510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 004266
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------