Provider Demographics
NPI:1942714308
Name:MARA J. BRANDON
Entity Type:Organization
Organization Name:MARA J. BRANDON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CASAC
Authorized Official - Phone:646-632-5377
Mailing Address - Street 1:310 W END AVE APT 1-C
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:
Practice Address - Street 1:310 W END AVE APT 1-C
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085699251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health