Provider Demographics
NPI:1700941747
Name:BRANDT, ELIZABETH JEANNE (MA)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:JEANNE
Last Name:BRANDT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7002 GRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4057
Mailing Address - Country:US
Mailing Address - Phone:317-849-4342
Mailing Address - Fax:317-558-1348
Practice Address - Street 1:7002 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4057
Practice Address - Country:US
Practice Address - Phone:317-849-4342
Practice Address - Fax:317-558-1348
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340025481041C0700X
IN35000196106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11422736OtherCAQH
IN000000350069OtherBLUE CROSS BLUE SHIELD