Provider Demographics
NPI:1740779511
Name:BRANDON, MARIANNE (PHD)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:BRANDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WALNUT ST STE 202
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY HILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02481-2105
Mailing Address - Country:US
Mailing Address - Phone:410-280-3888
Mailing Address - Fax:
Practice Address - Street 1:MARIANNE BRANDON PHD
Practice Address - Street 2:25 WALNUT ST #202
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:410-280-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2929103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10542OtherMA PSYCHOLOGY LICENSE