Provider Demographics
NPI:1063524312
Name:BRANTON, SANDRA L (EDD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:BRANTON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550547
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96155-0010
Mailing Address - Country:US
Mailing Address - Phone:530-541-5977
Mailing Address - Fax:530-577-4686
Practice Address - Street 1:870 EMERALD BAY RD
Practice Address - Street 2:SUITE 305
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-9403
Practice Address - Country:US
Practice Address - Phone:530-541-5977
Practice Address - Fax:530-577-4686
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11992103T00000X
NVPY0299103T00000X
CAMFC18217106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB0836AMedicare PIN