Provider Demographics
NPI:1518541085
Name:DEADWYLER, BRENDA RENA
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:RENA
Last Name:DEADWYLER
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 1:568 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7741
Mailing Address - Country:US
Mailing Address - Phone:310-766-4747
Mailing Address - Fax:
Practice Address - Street 1:568 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7741
Practice Address - Country:US
Practice Address - Phone:310-766-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP8247235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist