Provider Demographics
NPI:1215494836
Name:SOARES, BRANDON RICHARD
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:RICHARD
Last Name:SOARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 SANTA CRUZ WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-3757
Mailing Address - Country:US
Mailing Address - Phone:825-207-4901
Mailing Address - Fax:
Practice Address - Street 1:7001A EAST PKWY # 800
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2501
Practice Address - Country:US
Practice Address - Phone:916-336-1408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1196291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program