1801067764 NPI number — MANDY LYN BRANTLEY MSW, LCSW

Table of content: MANDY LYN BRANTLEY MSW, LCSW (NPI 1801067764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801067764 NPI number — MANDY LYN BRANTLEY MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANTLEY
Provider First Name:
MANDY
Provider Middle Name:
LYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OWENS
Provider Other First Name:
MANDY
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801067764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1508 BIRCHWOOD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE GIRARDEAU
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63701-2964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-780-6286
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1508 BIRCHWOOD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63701-2964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-780-6286
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  2002027571 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 52647 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)