Provider Demographics
NPI:1174967384
Name:BRANNON, SANDRA LYNEE' (MS)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LYNEE'
Last Name:BRANNON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:BRANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:1501 TAYLOR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98421-4100
Mailing Address - Country:US
Mailing Address - Phone:253-302-1624
Mailing Address - Fax:253-858-2254
Practice Address - Street 1:6712 KIMBALL DR
Practice Address - Street 2:STE. 103
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1212
Practice Address - Country:US
Practice Address - Phone:253-302-1624
Practice Address - Fax:253-858-2254
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG 60128134106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist