Provider Demographics
NPI:1124105622
Name:BRANHAM, MARIANNE BAILEY (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARIANNE
Middle Name:BAILEY
Last Name:BRANHAM
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 1:801 SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:ROCHEPORT
Mailing Address - State:MO
Mailing Address - Zip Code:65279-9011
Mailing Address - Country:US
Mailing Address - Phone:573-673-6799
Mailing Address - Fax:
Practice Address - Street 1:2716 FORUM BLVD.
Practice Address - Street 2:SUITE 4B
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5450
Practice Address - Country:US
Practice Address - Phone:573-817-9611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW005043101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497961037Medicaid
MO497961037Medicaid