Provider Demographics
NPI:1750809760
Name:OSTWALT, BRANDON (MA, LPCA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:OSTWALT
Suffix:
Gender:M
Credentials:MA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 HICKS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TROUTMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28166-8667
Mailing Address - Country:US
Mailing Address - Phone:704-929-8270
Mailing Address - Fax:
Practice Address - Street 1:913 N CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3414
Practice Address - Country:US
Practice Address - Phone:704-871-0934
Practice Address - Fax:704-871-9419
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13294101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health