Provider Demographics
NPI:1508102443
Name:KLEPACK, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:KLEPACK
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:PO BOX 403522
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140
Mailing Address - Country:US
Mailing Address - Phone:786-277-6398
Mailing Address - Fax:
Practice Address - Street 1:4701 N. MERIDIAN
Practice Address - Street 2:# 403522
Practice Address - City:MIAMIA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140
Practice Address - Country:US
Practice Address - Phone:786-277-6398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2530101YM0800X
FL101YP2500X
FLMT1386106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist