Provider Demographics
NPI:1063676658
Name:SPINA, BRENDA L (BRENDA SPINA, MS)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:SPINA
Suffix:
Gender:F
Credentials:BRENDA SPINA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1476 KENWOOD CTR
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1134
Mailing Address - Country:US
Mailing Address - Phone:920-720-8872
Mailing Address - Fax:920-720-8873
Practice Address - Street 1:1476 KENWOOD CTR
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1134
Practice Address - Country:US
Practice Address - Phone:920-720-8872
Practice Address - Fax:920-720-8873
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI520-125101YP2500X
WI136-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional