Provider Demographics
NPI:1053797126
Name:BRANTLEY, PATRICE (LMHC)
Entity type:Individual
Prefix:
First Name:PATRICE
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 GUNN HWY
Mailing Address - Street 2:APT 303
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-8785
Mailing Address - Country:US
Mailing Address - Phone:305-450-7655
Mailing Address - Fax:
Practice Address - Street 1:6323 MEMORIAL HWY
Practice Address - Street 2:SUITE A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4509
Practice Address - Country:US
Practice Address - Phone:813-891-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12978101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional