MEDICARE: DR. S BERLIN BRAHNAM PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	102L00000X	Psychoanalyst

General Provider Information

NPI Number	:	1013304575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. S BERLIN BRAHNAM PH.D.

Provider Business Mailing Address
First Line	:	4319 S NATIONAL AVE
Second Line	:	#259
City	:	SPRINGFIELD
State	:	MO
Zip	:	65810-2607
Country	:	US
Telephone Number	:	417-885-9171
Fax Number	:

Provider Business Practice Location Address
First Line	:	3543 S LONE PINE AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4854
Country	:	US
Telephone Number	:	417-885-9171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	04/22/2015

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