Provider Demographics
NPI:1194044149
Name:TENNANT, BRENDA (LCSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:TENNANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CONDOR CIR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-3360
Mailing Address - Country:US
Mailing Address - Phone:208-870-4274
Mailing Address - Fax:
Practice Address - Street 1:820 S LATAH ST STE 106
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2255
Practice Address - Country:US
Practice Address - Phone:208-572-2883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW325901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1194044149Medicaid