Provider Demographics
NPI:1477804615
Name:BRANTLEY, NICOLE (LCSWA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 PARKWAY PLAZA BLVD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1970
Mailing Address - Country:US
Mailing Address - Phone:704-423-0051
Mailing Address - Fax:704-329-0190
Practice Address - Street 1:4824 PARKWAY PLAZA BLVD
Practice Address - Street 2:SUITE 290
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1970
Practice Address - Country:US
Practice Address - Phone:704-423-0051
Practice Address - Fax:704-329-0190
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0065941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical