Provider Demographics
NPI:1508464900
Name:BRANTCH, CONETTA EMBODU NATASHA
Entity Type:Individual
Prefix:
First Name:CONETTA
Middle Name:EMBODU NATASHA
Last Name:BRANTCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18535 JORDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2305
Mailing Address - Country:US
Mailing Address - Phone:917-435-8070
Mailing Address - Fax:
Practice Address - Street 1:18535 JORDAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2305
Practice Address - Country:US
Practice Address - Phone:917-435-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085956-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty