Provider Demographics
NPI:1891123907
Name:BRANDON, MARA J (LCSW, CASAC 2)
Entity Type:Individual
Prefix:MS
First Name:MARA
Middle Name:J
Last Name:BRANDON
Suffix:
Gender:F
Credentials:LCSW, CASAC 2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W END AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-8146
Mailing Address - Country:US
Mailing Address - Phone:646-632-5377
Mailing Address - Fax:212-313-9419
Practice Address - Street 1:310 W END AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-8146
Practice Address - Country:US
Practice Address - Phone:646-632-5377
Practice Address - Fax:212-313-9419
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21232101YA0400X
NY084080104100000X
NY0856991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY5631735OtherCIGNA
NYG100000410Medicare Oscar/Certification
WI331978Medicare Oscar/Certification
WI321952Medicare Oscar/Certification
WI331946Medicare Oscar/Certification
WI331954Medicare Oscar/Certification
WI331009Medicare Oscar/Certification
NY00695941Medicaid
WI331058Medicare Oscar/Certification
WI331944Medicare Oscar/Certification
WI331043Medicare Oscar/Certification
NYW6L111Medicare Oscar/Certification
WI331945Medicare Oscar/Certification