Basic Information
| Provider Information | |||||||||
| NPI: | 1285827691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURHAM | ||||||||
| FirstName: | BRANDON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 395 BALLANTYNE ST | ||||||||
| Address2: | #305 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920203922 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 395 BALLANTYNE ST | ||||||||
| Address2: | #305 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920203922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195883653 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2007 | ||||||||
| LastUpdateDate: | 08/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.