Provider Demographics
NPI:1568625895
Name:HAVELLANA, BRENDA KAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:KAY
Last Name:HAVELLANA
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 1:3224 75TH DR NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-6804
Mailing Address - Country:US
Mailing Address - Phone:425-387-6972
Mailing Address - Fax:
Practice Address - Street 1:5105 200TH ST SW
Practice Address - Street 2:SUITE 100
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6397
Practice Address - Country:US
Practice Address - Phone:425-387-6972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60014648103G00000X, 103TC0700X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical