Provider Demographics
NPI:1871062950
Name:BRANTLEY, MANDY S DELOIS (MS)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:S DELOIS
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 FRUITVALE AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2150
Mailing Address - Country:US
Mailing Address - Phone:334-791-1703
Mailing Address - Fax:
Practice Address - Street 1:1477 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2028
Practice Address - Country:US
Practice Address - Phone:334-692-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-18
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty