MEDICARE: NICOLE MARIANNE BRANT

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	101YM0800X	Mental Health Counselor	0701015468	VA

General Provider Information

NPI Number	:	1417800467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIANNE BRANT

Provider Business Mailing Address
First Line	:	4401 DAVIS FAIRFAX LN
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-5580
Country	:	US
Telephone Number	:	787-464-5395
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 KINTORE CIR APT 203
Second Line	:
City	:	ODENTON
State	:	MD
Zip	:	21113-4611
Country	:	US
Telephone Number	:	787-464-5395
Fax Number	:

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

Provider Enumeration Date	:	02/18/2026
Last Update Date	:	03/15/2026

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