Provider Demographics
NPI:1982944682
Name:VANBRACKLE, DENISE BURT (LCSW)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:BURT
Last Name:VANBRACKLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CHASTAIN ROAD
Mailing Address - Street 2:KSU HOUSE 53
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144
Mailing Address - Country:US
Mailing Address - Phone:678-797-2018
Mailing Address - Fax:
Practice Address - Street 1:1000 CHASTAIN ROAD
Practice Address - Street 2:HOUSE 53
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:678-797-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0031121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBFMVMedicare PIN