Healthcare Provider Details

I. General information

NPI: 1861834475
Provider Name (Legal Business Name): BRENDA MASSICOTT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. BRENDA CONWAY

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9401 WHITE CEDAR DR APT 309
OWINGS MILLS MD
21117-7516
US

IV. Provider business mailing address

1450 RANCHO GRANDE DR.
HOUSTON TX
77049
US

V. Phone/Fax

Practice location:
  • Phone: 410-830-9113
  • Fax:
Mailing address:
  • Phone: 410-830-9113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number101YM0800X
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number172V00000X
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: