Provider Demographics
NPI:1649798158
Name:DEVEZIN, BRANDON G I (MHP)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:G
Last Name:DEVEZIN
Suffix:I
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 LAPEYROUSE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-2633
Mailing Address - Country:US
Mailing Address - Phone:504-235-5035
Mailing Address - Fax:
Practice Address - Street 1:3630 MACARTHUR BLVD STE A
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-6871
Practice Address - Country:US
Practice Address - Phone:504-235-5035
Practice Address - Fax:504-235-5035
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty