Provider Demographics
NPI:1043952401
Name:MENDOZA, BRENDA M (RBT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:M
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MECHANIC ST # 484
Mailing Address - Street 2:
Mailing Address - City:EAST BROOKFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01515-9800
Mailing Address - Country:US
Mailing Address - Phone:413-459-9565
Mailing Address - Fax:833-431-1244
Practice Address - Street 1:238 GRAY RD
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:MA
Practice Address - Zip Code:01468-1142
Practice Address - Country:US
Practice Address - Phone:978-895-9585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARBT-22-210783106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician