Provider Demographics
NPI:1073840260
Name:NOUR, BRENDA MICHELLE LINDSAY (PHD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:MICHELLE LINDSAY
Last Name:NOUR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 W 69TH ST STE 1500
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8171
Mailing Address - Country:US
Mailing Address - Phone:605-480-1482
Mailing Address - Fax:
Practice Address - Street 1:4400 W 69TH ST STE 1500
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8171
Practice Address - Country:US
Practice Address - Phone:605-480-1482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3365103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6550210Medicaid
SDS103842Medicare PIN