Provider Demographics
NPI:1861834475
Name:MASSICOTT, BRENDA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:MASSICOTT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1450 RANCHO GRANDE DR.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77049
Mailing Address - Country:US
Mailing Address - Phone:410-830-9113
Mailing Address - Fax:
Practice Address - Street 1:9401 WHITE CEDAR DR
Practice Address - Street 2:APT 309
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-7516
Practice Address - Country:US
Practice Address - Phone:410-830-9113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD172V00000X172V00000X
MD101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker