Provider Demographics
NPI:1063988939
Name:CLARK, BRANDON K (LCDC-I)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:K
Last Name:CLARK
Suffix:
Gender:M
Credentials:LCDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 MARTIN LUTHER KING JR AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:GRAMBLING
Mailing Address - State:LA
Mailing Address - Zip Code:71245-2113
Mailing Address - Country:US
Mailing Address - Phone:318-607-4302
Mailing Address - Fax:
Practice Address - Street 1:2400 S LOOP W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2800
Practice Address - Country:US
Practice Address - Phone:832-429-7219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator