Provider Demographics
NPI:1801067764
Name:BRANTLEY, MANDY LYN (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:LYN
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:LYN
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:1508 BIRCHWOOD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2964
Mailing Address - Country:US
Mailing Address - Phone:314-780-6286
Mailing Address - Fax:
Practice Address - Street 1:1508 BIRCHWOOD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2964
Practice Address - Country:US
Practice Address - Phone:314-780-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020275711041C0700X
TX526471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical