1982078382 NPI number — BRANDY K PORTER LCSW, CAADC

Table of content: BRANDY K PORTER LCSW, CAADC (NPI 1982078382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982078382 NPI number — BRANDY K PORTER LCSW, CAADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
BRANDY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, CAADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ODENWELDER
Provider Other First Name:
BRANDY
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCAS, LCSWA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982078382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5905 STEWART PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30135-2371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-949-8082
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5905 STEWART PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30135-2371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-949-8082
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2015

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: 101YA0400X , with the licence number:  C0245 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: MSW008124 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1982078382 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com