Provider Demographics
NPI:1275046385
Name:GANDARA, BRENDA LILIANA (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:LILIANA
Last Name:GANDARA
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 1:15615 ALTON PKWY STE 230
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-7306
Mailing Address - Country:US
Mailing Address - Phone:949-528-6300
Mailing Address - Fax:
Practice Address - Street 1:15615 ALTON PKWY STE 230
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-7306
Practice Address - Country:US
Practice Address - Phone:949-528-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
225400000X, 225C00000X
CAPSY31390103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor