Provider Demographics
NPI:1629688650
Name:REA, BRENDA YESENIA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:YESENIA
Last Name:REA
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:PO BOX 1851
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-1851
Mailing Address - Country:US
Mailing Address - Phone:323-245-5501
Mailing Address - Fax:
Practice Address - Street 1:3780 KILROY AIRPORT WAY STE 200
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2458
Practice Address - Country:US
Practice Address - Phone:323-548-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1052500106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician