Basic Information
Provider Information | |||||||||
NPI: | 1932420379 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MACBRAYNE | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13395 N MARANA MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MARANA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856537008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206824111 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5224 W DOVE CENTRE RD | ||||||||
Address2: |   | ||||||||
City: | MARANA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856585063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206161445 | ||||||||
FaxNumber: | 5206161446 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2010 | ||||||||
LastUpdateDate: | 09/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 2010019097 | MO | N |   | Behavioral Health & Social Service Providers | Counselor |   | 363LP0808X | AP9909 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 246176 | 05 | AZ |   | MEDICAID |