Provider Demographics
NPI:1104573740
Name:MARTIN, BRANDY
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 SUNCREST DR
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-1154
Mailing Address - Country:US
Mailing Address - Phone:810-667-0500
Mailing Address - Fax:810-664-8728
Practice Address - Street 1:51145 NICOLETTE DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-4585
Practice Address - Country:US
Practice Address - Phone:586-228-9991
Practice Address - Fax:586-228-9902
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician