Provider Demographics
NPI:1982078382
Name:PORTER, BRANDY K (LCSW, CAADC)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:K
Last Name:PORTER
Suffix:
Gender:F
Credentials:LCSW, CAADC
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:K
Other - Last Name:ODENWELDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCAS, LCSWA
Mailing Address - Street 1:5905 STEWART PKWY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2371
Mailing Address - Country:US
Mailing Address - Phone:770-949-8082
Mailing Address - Fax:
Practice Address - Street 1:5905 STEWART PKWY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-2371
Practice Address - Country:US
Practice Address - Phone:770-949-8082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0245101YA0400X
GAMSW0081241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1982078382Medicaid