Provider Demographics
NPI:1033766423
Name:RAINWATER, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:RAINWATER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 KNIGHT ST STE 155
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2412
Mailing Address - Country:US
Mailing Address - Phone:318-213-1887
Mailing Address - Fax:318-629-2870
Practice Address - Street 1:2920 KNIGHT ST STE 155
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2412
Practice Address - Country:US
Practice Address - Phone:318-429-6938
Practice Address - Fax:318-629-2870
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LAPLC9925101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator