Provider Demographics
NPI:1063036333
Name:BRAINARD, STEPHANIE MARILYN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARILYN
Last Name:BRAINARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12825 W SWEETWATER AVE
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-7276
Mailing Address - Country:US
Mailing Address - Phone:602-690-7877
Mailing Address - Fax:
Practice Address - Street 1:20470 N LAKE PLEASANT RD STE 107
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9708
Practice Address - Country:US
Practice Address - Phone:602-690-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
BACB542120OtherBACB