=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851106702
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREANNA DESANDRO LPCC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5800 MONROE ST
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-2263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-436-1345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4407 VOGEL DR
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43613-3116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-476-3646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | BREANNA DESANDRO
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 734-436-1345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------