Provider Demographics
NPI:1225221757
Name:INTERIAN-BOYSSELLE, BRENDA (LPC)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
Last Name:INTERIAN-BOYSSELLE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:PATRICIA
Other - Last Name:INTERIAN-MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1814 BURL LN
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-4651
Mailing Address - Country:US
Mailing Address - Phone:903-372-0843
Mailing Address - Fax:469-854-4998
Practice Address - Street 1:1514 N GREENVILLE AVE STE 310
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-1205
Practice Address - Country:US
Practice Address - Phone:903-372-0843
Practice Address - Fax:469-854-4998
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62135101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187164201Medicaid
TX1225221757OtherHUMANA HEALTHCARE SERVICES, TRICARE