Provider Demographics
NPI:1093982118
Name:TICKNOR, BRENDA L (LIMHP, LMHC, SADC, L)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:L
Last Name:TICKNOR
Suffix:
Gender:F
Credentials:LIMHP, LMHC, SADC, L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 S. 11TH STREET
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-7407
Mailing Address - Country:US
Mailing Address - Phone:402-616-9876
Mailing Address - Fax:712-355-5120
Practice Address - Street 1:427 E. KANESVILLE BLVD.
Practice Address - Street 2:SUITE 308
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4499
Practice Address - Country:US
Practice Address - Phone:402-616-9876
Practice Address - Fax:712-355-5120
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4316101YM0800X
NE814101YA0400X
NE2098101Y00000X
NE9295101YM0800X
NE1543101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE9295OtherPLMHP
NE814OtherLADC
NE$$$$$$$$$Medicaid