Healthcare Provider Details

I. General information

NPI: 1003323262
Provider Name (Legal Business Name): KIMBERLY BRANDL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 WALTON ST STE 200
SYRACUSE NY
13202-1373
US

IV. Provider business mailing address

141 COUNTY ROUTE 23A
CONSTANTIA NY
13044-3737
US

V. Phone/Fax

Practice location:
  • Phone: 315-204-0610
  • Fax: 315-260-4332
Mailing address:
  • Phone: 315-204-0610
  • Fax: 315-260-4332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPO3869
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: