Provider Demographics
NPI:1972974087
Name:BRAINERD, MICHAEL PAUL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:BRAINERD
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:PO BOX 2077
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2077
Mailing Address - Country:US
Mailing Address - Phone:707-467-2010
Mailing Address - Fax:
Practice Address - Street 1:7690 EAST ROAD
Practice Address - Street 2:
Practice Address - City:REDWOOD VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95470-9548
Practice Address - Country:US
Practice Address - Phone:707-467-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator