Provider Demographics
NPI:1609001775
Name:BRANCH, MATTIE BARNES
Entity Type:Individual
Prefix:MRS
First Name:MATTIE
Middle Name:BARNES
Last Name:BRANCH
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 1:2413 CRABTREE BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-2299
Mailing Address - Country:US
Mailing Address - Phone:919-899-6740
Mailing Address - Fax:919-899-6741
Practice Address - Street 1:2413 CRABTREE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-2299
Practice Address - Country:US
Practice Address - Phone:919-899-6740
Practice Address - Fax:919-899-6741
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001207-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health