Provider Demographics
NPI:1003582636
Name:LONDON, BRENA
Entity Type:Individual
Prefix:
First Name:BRENA
Middle Name:
Last Name:LONDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENA
Other - Middle Name:
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8542 W GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-2326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8542 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2326
Practice Address - Country:US
Practice Address - Phone:734-449-4649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician