Provider Demographics
NPI:1093138687
Name:BLOCKUS, BRENDA (MS)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:BLOCKUS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3726 HAMPTON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-3867
Mailing Address - Country:US
Mailing Address - Phone:570-262-5930
Mailing Address - Fax:
Practice Address - Street 1:3726 HAMPTON HILLS DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-3867
Practice Address - Country:US
Practice Address - Phone:570-262-5930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor