Provider Demographics
NPI:1609376680
Name:COTTRELL, BRANDY NICHOLE (CDCA)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:NICHOLE
Last Name:COTTRELL
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-0108
Mailing Address - Country:US
Mailing Address - Phone:740-532-1613
Mailing Address - Fax:740-532-1715
Practice Address - Street 1:700 PARK AVE
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638
Practice Address - Country:US
Practice Address - Phone:740-532-1613
Practice Address - Fax:740-532-1715
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.166506171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0263935Medicaid