MEDICARE: KATHERINE LONG BRANTLEY LICSW, PIP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	3849C	AL

General Provider Information

NPI Number	:	1083100044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE LONG BRANTLEY LICSW, PIP

Provider Business Mailing Address
First Line	:	442 LIGHTNESS DR
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36832-5113
Country	:	US
Telephone Number	:	205-482-1429
Fax Number	:

Provider Business Practice Location Address
First Line	:	318 N COLLEGE ST STE G
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-3815
Country	:	US
Telephone Number	:	334-329-6063
Fax Number	:	334-329-6063

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2018
Last Update Date	:	07/02/2018

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