Provider Demographics
NPI:1548241698
Name:BRENTZEL, JOAN CAROL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:CAROL
Last Name:BRENTZEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15706 POMERADO RD
Mailing Address - Street 2:#210
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2067
Mailing Address - Country:US
Mailing Address - Phone:858-451-0027
Mailing Address - Fax:858-451-2419
Practice Address - Street 1:15706 POMERADO RD
Practice Address - Street 2:#210
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2067
Practice Address - Country:US
Practice Address - Phone:858-451-0027
Practice Address - Fax:858-451-2419
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9229103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPS0092290Medicaid
CAR62398Medicare ID - Type Unspecified
1865414Medicare UPIN