Basic Information
| Provider Information | |||||||||
| NPI: | 1164580502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRASHAW | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MFT I | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 474 | ||||||||
| Address2: | |||||||||
| City: | FOREST RANCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308921417 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2858 OLIVE HIGHWAY | ||||||||
| Address2: | SUITES A, B, & C | ||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305382158 | ||||||||
| FaxNumber: | 5305337188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFTI 48878 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 48878 | 01 | CA | IMF | OTHER |