Basic Information
Provider Information | |||||||||
NPI: | 1598394660 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRANDIMORE | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | WADE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LBSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 38 | ||||||||
Address2: |   | ||||||||
City: | SACATON | ||||||||
State: | AZ | ||||||||
PostalCode: | 851470001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6025287135 | ||||||||
FaxNumber: | 6025281374 | ||||||||
Practice Location | |||||||||
Address1: | 291 W CASA BLANCA RD. | ||||||||
Address2: | BLDG. 7 | ||||||||
City: | SACATON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5205623323 | ||||||||
FaxNumber: | 6025281374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2020 | ||||||||
LastUpdateDate: | 04/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LBSW-0959 | AZ | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.