Provider Demographics
NPI:1760578470
Name:VANBRONKHORST, MARIAN H (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:MARIAN
Middle Name:H
Last Name:VANBRONKHORST
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:HEASLEY
Other - Last Name:VANBRONKHORST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS IN PC
Mailing Address - Street 1:19000 SOUSA WAY
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-3142
Mailing Address - Country:US
Mailing Address - Phone:301-330-3373
Mailing Address - Fax:301-330-0405
Practice Address - Street 1:19000 SOUSA WAY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-3142
Practice Address - Country:US
Practice Address - Phone:301-330-3373
Practice Address - Fax:301-330-0405
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC0167101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC0167OtherLCPC