Provider Demographics
NPI:1235258583
Name:BRANDENBURG, MARY PRATT (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PRATT
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5570 STERRETT PL
Mailing Address - Street 2:SUITE 308
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2641
Mailing Address - Country:US
Mailing Address - Phone:410-997-7040
Mailing Address - Fax:410-997-7041
Practice Address - Street 1:5570 STERRETT PL
Practice Address - Street 2:SUITE 308
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2641
Practice Address - Country:US
Practice Address - Phone:410-997-7040
Practice Address - Fax:410-997-7041
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU00196171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD412684-02OtherCAREFIRST NON-PAR #