Provider Demographics
NPI:1609088012
Name:POLL, BRENDA IRA (PHD, PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:IRA
Last Name:POLL
Suffix:
Gender:F
Credentials:PHD, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 FONTANA WAY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-4053
Mailing Address - Country:US
Mailing Address - Phone:949-715-9019
Mailing Address - Fax:
Practice Address - Street 1:111 PACIFICA
Practice Address - Street 2:SUITE 270
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3310
Practice Address - Country:US
Practice Address - Phone:949-341-0393
Practice Address - Fax:949-715-9029
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10179103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical