Provider Demographics
NPI:1730943150
Name:HART, BRANDON CHARLES (LADC 2)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:CHARLES
Last Name:HART
Suffix:
Gender:M
Credentials:LADC 2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 MID-IRON WAY
Mailing Address - Street 2:
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649
Mailing Address - Country:US
Mailing Address - Phone:774-521-5662
Mailing Address - Fax:
Practice Address - Street 1:7525 MID-IRON WAY
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649
Practice Address - Country:US
Practice Address - Phone:774-521-5662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23149101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty