Provider Demographics
NPI:1073751053
Name:BRANCH, ALISA MASHANDA (LPC)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:MASHANDA
Last Name:BRANCH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4944 GREENSBORO RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148-3390
Mailing Address - Country:US
Mailing Address - Phone:276-956-2233
Mailing Address - Fax:276-956-1629
Practice Address - Street 1:4944 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:VA
Practice Address - Zip Code:24148-3390
Practice Address - Country:US
Practice Address - Phone:276-956-2233
Practice Address - Fax:276-956-1629
Is Sole Proprietor?:No
Enumeration Date:2009-01-28
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008513101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1689182164Medicaid