Provider Demographics
NPI:1023409406
Name:TREADWELL, BRANDON TY (BACHELOR'S DEGREE)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:TY
Last Name:TREADWELL
Suffix:
Gender:M
Credentials:BACHELOR'S DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 E COOLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3905
Mailing Address - Country:US
Mailing Address - Phone:909-580-3731
Mailing Address - Fax:
Practice Address - Street 1:1330 E COOLEY DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3905
Practice Address - Country:US
Practice Address - Phone:909-580-3731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA373H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist