Provider Demographics
NPI:1104293489
Name:GREENSTREET, BRANDON (MA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:GREENSTREET
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:TUNDRA
Other - Middle Name:
Other - Last Name:GREENSTREET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:724 27TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7042
Mailing Address - Country:US
Mailing Address - Phone:907-374-2905
Mailing Address - Fax:907-374-2915
Practice Address - Street 1:724 27TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7042
Practice Address - Country:US
Practice Address - Phone:907-374-2905
Practice Address - Fax:907-374-2915
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health