Provider Demographics
NPI:1083785570
Name:BRANCH, MAMIE MARIE (LSW)
Entity Type:Individual
Prefix:MS
First Name:MAMIE
Middle Name:MARIE
Last Name:BRANCH
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3363
Mailing Address - Country:US
Mailing Address - Phone:973-416-8032
Mailing Address - Fax:
Practice Address - Street 1:273 OLIVER ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-2507
Practice Address - Country:US
Practice Address - Phone:973-522-2122
Practice Address - Fax:973-522-0437
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL051838001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical