Provider Demographics
NPI:1437391745
Name:BRENDA, KRISTIE MARIE
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:MARIE
Last Name:BRENDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 PIONEER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2133
Mailing Address - Country:US
Mailing Address - Phone:831-459-0444
Mailing Address - Fax:
Practice Address - Street 1:290 PIONEER ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2133
Practice Address - Country:US
Practice Address - Phone:831-459-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4424Medicaid