Provider Demographics
NPI:1245651157
Name:BRANDEBURA, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BRANDEBURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 KENNEDY ST REAR
Mailing Address - Street 2:
Mailing Address - City:CARNEGIE
Mailing Address - State:PA
Mailing Address - Zip Code:15106-3163
Mailing Address - Country:US
Mailing Address - Phone:412-983-6616
Mailing Address - Fax:
Practice Address - Street 1:6315 FORBES AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15217-1745
Practice Address - Country:US
Practice Address - Phone:412-983-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007218101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional