Provider Demographics
NPI:1881870194
Name:LICHTMAN, BRANDON S (AUD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:S
Last Name:LICHTMAN
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MEDICAL PARK
Mailing Address - Street 2:STE 223
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6391
Mailing Address - Country:US
Mailing Address - Phone:304-243-7879
Mailing Address - Fax:304-243-3901
Practice Address - Street 1:30 MEDICAL PARK
Practice Address - Street 2:STE 223
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6391
Practice Address - Country:US
Practice Address - Phone:304-243-7879
Practice Address - Fax:304-243-3901
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA-0267231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018801Medicaid
WVCD2989OtherRAIL ROAD MEDICARE
WV7419991Medicare PIN