Provider Demographics
NPI:1558038695
Name:GARY, BRANDAIS QUAY
Entity type:Individual
Prefix:
First Name:BRANDAIS
Middle Name:QUAY
Last Name:GARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRANDAIS
Other - Middle Name:
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:123 HAMPDEN DR APT J
Mailing Address - Street 2:
Mailing Address - City:MOUNTVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17554-1800
Mailing Address - Country:US
Mailing Address - Phone:717-824-6370
Mailing Address - Fax:
Practice Address - Street 1:123 HAMPDEN DR APT J
Practice Address - Street 2:
Practice Address - City:MOUNTVILLE
Practice Address - State:PA
Practice Address - Zip Code:17554-1800
Practice Address - Country:US
Practice Address - Phone:717-824-6370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC015606101YP2500X
PA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional