Provider Demographics
NPI:1003323262
Name:BRANDL, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BRANDL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 COUNTY ROUTE 23A
Mailing Address - Street 2:
Mailing Address - City:CONSTANTIA
Mailing Address - State:NY
Mailing Address - Zip Code:13044-3737
Mailing Address - Country:US
Mailing Address - Phone:315-204-0610
Mailing Address - Fax:315-260-4332
Practice Address - Street 1:5701 E CIRCLE DR # 163
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-8638
Practice Address - Country:US
Practice Address - Phone:315-204-0610
Practice Address - Fax:315-260-4332
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPO3869101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health