Healthcare Provider Details

I. General information

NPI: 1114900412
Provider Name (Legal Business Name): MARTHA ANN BRANDT LCSW ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 COVERT AVE SUITE 230
EVANSVILLE IN
47714-5668
US

IV. Provider business mailing address

4770 COVERT AVE SUITE 230
EVANSVILLE IN
47714-5668
US

V. Phone/Fax

Practice location:
  • Phone: 812-475-3420
  • Fax: 812-475-3470
Mailing address:
  • Phone: 812-475-3420
  • Fax: 812-475-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberIN34002317A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: