Provider Demographics
NPI:1801864913
Name:BRAND, MICHAEL W (LCSW PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:BRAND
Suffix:
Gender:M
Credentials:LCSW PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 NORTHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-3263
Mailing Address - Country:US
Mailing Address - Phone:405-275-3939
Mailing Address - Fax:
Practice Address - Street 1:1100 NE 13TH ST
Practice Address - Street 2:CSC
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1039
Practice Address - Country:US
Practice Address - Phone:405-271-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200021540AMedicaid
OK200021540AMedicaid