Provider Demographics
NPI:1174893267
Name:BRANDSTRUP, NICOLE KATHERINE (PC-PROV, ATR-BC)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:KATHERINE
Last Name:BRANDSTRUP
Suffix:
Gender:F
Credentials:PC-PROV, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 EXECUTIVE PKWY FL 8
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-5530
Mailing Address - Country:US
Mailing Address - Phone:419-720-9000
Mailing Address - Fax:419-720-9002
Practice Address - Street 1:3130 EXECUTIVE PKWY FL 8
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-5530
Practice Address - Country:US
Practice Address - Phone:419-720-9000
Practice Address - Fax:419-720-9002
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1000106.PROV.101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC.1000106.PROV.OtherCOUNSELOR LICENSE