Healthcare Provider Details

I. General information

NPI: 1023734308
Provider Name (Legal Business Name): ELLEN ELIZABETH BRANDENBURG LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 W JOPPA ROAD
TIMONIUM MD
21093
US

IV. Provider business mailing address

7990 OLD GEORGETOWN RD SUITES 9B, 10B AND 10A
BETHESDA MD
20814-2551
US

V. Phone/Fax

Practice location:
  • Phone: 301-718-4544
  • Fax:
Mailing address:
  • Phone: 301-718-4544
  • Fax: 301-478-9899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24300
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: