Provider Demographics
NPI:1588169544
Name:GOLDER, BRANDY LEE
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:LEE
Last Name:GOLDER
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 1:5895 WALSH PT APT 208
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2043
Mailing Address - Country:US
Mailing Address - Phone:719-679-7961
Mailing Address - Fax:719-434-2085
Practice Address - Street 1:5895 WALSH PT APT 208
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-2043
Practice Address - Country:US
Practice Address - Phone:719-679-7961
Practice Address - Fax:719-434-2085
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-18-52290106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician