Provider Demographics
NPI:1003277674
Name:TUDOR, BRENDEN ARIAS (LLPC, AT)
Entity Type:Individual
Prefix:
First Name:BRENDEN
Middle Name:ARIAS
Last Name:TUDOR
Suffix:
Gender:M
Credentials:LLPC, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-2468
Mailing Address - Country:US
Mailing Address - Phone:231-767-1921
Mailing Address - Fax:
Practice Address - Street 1:1611 OAK AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-2468
Practice Address - Country:US
Practice Address - Phone:231-767-1921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010019632255A2300X
2255A2300X, 390200000X
MI6401018626101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program