Provider Demographics
NPI:1780806059
Name:BRANDT, EDNA MARIE (LAC)
Entity type:Individual
Prefix:MS
First Name:EDNA
Middle Name:MARIE
Last Name:BRANDT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 MAIN STREETSUITE 149
Mailing Address - Street 2:SUITE 149
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707
Mailing Address - Country:US
Mailing Address - Phone:301-953-3413
Mailing Address - Fax:
Practice Address - Street 1:575 MAIN STREET
Practice Address - Street 2:SUITE 149
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707
Practice Address - Country:US
Practice Address - Phone:301-953-3413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2009-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU335171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD425027-01 AZ81OtherCAREFIRST BCBS