Basic Information
| Provider Information | |||||||||
| NPI: | 1619396603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDAL | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD, LMSW, LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4041 W SYLVANIA AVE | ||||||||
| Address2: | STE LL2 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318789198 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4041 W SYLVANIA AVE | ||||||||
| Address2: | STE LL2 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197244233 | ||||||||
| FaxNumber: | 8776227635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2014 | ||||||||
| LastUpdateDate: | 11/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801085300 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | I.2102932 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0455026 | 05 | OH | MEDICAID |