Healthcare Provider Details

I. General information

NPI: 1689245581
Provider Name (Legal Business Name): HEATHER BRANDENBURG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 GIBSON BAY DR STE 201
RICHMOND KY
40475-3544
US

IV. Provider business mailing address

1001 GIBSON BAY DR STE 201
RICHMOND KY
40475-3544
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 859-644-9033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number259567
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: