Healthcare Provider Details

I. General information

NPI: 1841737830
Provider Name (Legal Business Name): ANTTARCH BRANDY SR. LSW, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 GLASGOW DR
CINCINNATI OH
45240-2447
US

IV. Provider business mailing address

892 GLASGOW DR
CINCINNATI OH
45240-2447
US

V. Phone/Fax

Practice location:
  • Phone: 513-616-8774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.1000458
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: