Provider Demographics
NPI:1114900412
Name:BRANDT, MARTHA ANN (LCSW ACSW)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:ANN
Last Name:BRANDT
Suffix:
Gender:F
Credentials:LCSW ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 COVERT AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-5668
Mailing Address - Country:US
Mailing Address - Phone:812-475-3420
Mailing Address - Fax:812-475-3470
Practice Address - Street 1:4770 COVERT AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-5668
Practice Address - Country:US
Practice Address - Phone:812-475-3420
Practice Address - Fax:812-475-3470
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ34002317A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000290662OtherBCBS ANTHEM
5311045OtherAETNA
IN209730Medicare ID - Type Unspecified