Provider Demographics
NPI:1902564248
Name:BRANTLEY, DEIDRE KATRICE
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:KATRICE
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 HABITAT ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3472
Mailing Address - Country:US
Mailing Address - Phone:229-591-0465
Mailing Address - Fax:
Practice Address - Street 1:209 HABITAT ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3472
Practice Address - Country:US
Practice Address - Phone:229-591-0465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty