Provider Demographics
NPI:1366459042
Name:BRANDENBURG, JOAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 BROADWAY
Mailing Address - Street 2:SUITE D2
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2742
Mailing Address - Country:US
Mailing Address - Phone:631-598-3652
Mailing Address - Fax:631-598-3652
Practice Address - Street 1:137 BROADWAY
Practice Address - Street 2:SUITE D2
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2742
Practice Address - Country:US
Practice Address - Phone:631-598-3652
Practice Address - Fax:631-598-3652
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR029415-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7401088OtherEMPIRE GHI
NYP2744059OtherOXFORD INS
NYP2744059OtherOXFORD INS