Provider Demographics
NPI:1629488085
Name:FRAGOSA, BRENDA JAYNE DOLAN (MA)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:JAYNE DOLAN
Last Name:FRAGOSA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:DOLAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:1176 E WARNER RD
Mailing Address - Street 2:SUITE 111A
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3067
Mailing Address - Country:US
Mailing Address - Phone:480-892-1575
Mailing Address - Fax:844-272-6941
Practice Address - Street 1:1176 E WARNER RD
Practice Address - Street 2:SUITE 111A
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3067
Practice Address - Country:US
Practice Address - Phone:480-892-1575
Practice Address - Fax:844-272-6941
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT-15123106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist