Healthcare Provider Details

I. General information

NPI: 1063989473
Provider Name (Legal Business Name): BRANDIE MARIE CARLTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BUFORD RD STE 101
NORTH CHESTERFIELD VA
23235-5292
US

IV. Provider business mailing address

5031 KING COTTON LN
MIDLOTHIAN VA
23112-2853
US

V. Phone/Fax

Practice location:
  • Phone: 804-447-6382
  • Fax: 804-447-6383
Mailing address:
  • Phone: 804-617-0287
  • Fax: 804-447-6383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904010766
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: