Basic Information
| Provider Information | |||||||||
| NPI: | 1205198439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADY | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | COLLEEN SHANNON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHANNON | ||||||||
| OtherFirstName: | ROBIN | ||||||||
| OtherMiddleName: | COLLEEN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 975 FLYNN RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930128704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054457800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 975 FLYNN RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930128704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054457800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2012 | ||||||||
| LastUpdateDate: | 06/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 63798 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 221700000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist |
No ID Information.