Basic Information
| Provider Information | |||||||||
| NPI: | 1841721974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDON | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 27261 LAS RAMBLAS | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916441 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9500 HAVEN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917305807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099806700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2017 | ||||||||
| LastUpdateDate: | 11/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 171M00000X | D5017824 | CA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.