Provider Demographics
NPI:1295288181
Name:MARSICEK, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:MARSICEK
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 1:419 NE 71ST ST APT 407
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-5876
Mailing Address - Country:US
Mailing Address - Phone:906-295-0949
Mailing Address - Fax:
Practice Address - Street 1:419 NE 71ST ST APT 407
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115
Practice Address - Country:US
Practice Address - Phone:906-295-0949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2020-09-15
Deactivation Date:2018-01-23
Deactivation Code:
Reactivation Date:2019-07-03
Provider Licenses
StateLicense IDTaxonomies
WACG60675292101Y00000X
WAAB60967560106E00000X
WA61079809103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst