Provider Demographics
NPI:1235759556
Name:BRANHAM, ALYCE DANIELLE (LSW)
Entity Type:Individual
Prefix:
First Name:ALYCE
Middle Name:DANIELLE
Last Name:BRANHAM
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1234 E DUPONT RD STE 1
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1545
Practice Address - Country:US
Practice Address - Phone:260-425-6390
Practice Address - Fax:260-425-6395
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008853A1041C0700X
IN33008603A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker